Alcoholic hepatitis

Question 1

Patient with alcohol addiction with alcoholic hepatitis.

List two first-line agents, 3 second-line agents used to treat alcohol dependence.

Answer 1

1. Acamprosate
2. Naltrexone
3. Disulfiram
4. Topiramate
5. Baclofen
6. Nalmefene
7. Ondansetron

Question 2

Acamprosate and naltrexone.

Mechanism of action?

Answer 2

1. Acamprosate: weak NDMA receptor antagonist and decreases cravings. Good outcomes with combined psychological support.
2. Naltrexone: mu opioid receptor antagonist leading to reduction in alcohol induced rewards and cravings.

Question 3

Acamprosate

Side effects?

Answer 3

Arrhythmias
HTN or hypotension 
Allergic reactions
Insomnia 
Headaches
Diarrhoea 

Contraindicated in impaired renal function

Question 4

Naltrexone side effects? (gastro)

Answer 4

Liver damage at higher doses

GI disturbances

Question 5

Disulfiram

Mechanism of action?

Answer 5

It inhibits aldehyde dehydrogenase, leading to accumulation of acetylaldehyde and increasing unpleasant side effects of alcohol.

Question 6

Disulfiram

Side effects?

Answer 6

Nausea, vomiting, sweating, tachycardia, palpitations, hyperventilation, headache, panic, stress

Question 7

Topiramate

Mechanism of action?

Answer 7

Anti-epileptic. It enhances effects of GABA, and inhibits neurotransmission and decreases excitatory effects on CNS.

Question 8

Gabapentin

Mechanism of action?

Answer 8

Anticonvulsant. Increases production of GABA, inhibiting excitatory neurotransmission.

Question 9

What are non-pharmacological interventions available for alcohol dependence?

Answer 9

Motivational interviewing, CBT, patient education on different resources available for help.

Question 10

What medications are used for acute abstinence syndrome?

Answer 10

1. IV diazepam: modifies GABA receptors to increase activity, sedative effects to calm the patient down. Use loading dose technique
2. Thiamine + folic acid + multivitamins (prevention of Wernicke’s encephalopathy and Korsakoff’s syndrome long term.
3. Glucose: prevention of hypoglycaemia
4. Magnesium sulfate: regulating neuronal excitability and interferes calcium mediated neurotransmitter release.
5. Beta-blockers to reduce sympathetic activity.