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3.6.1 Seizures

When there is a history of withdrawal seizures, early treatment with diazepam is indicated – either diazepam loading or 40 mg on day 1.

Prophylactic treatment with anti-convulsants such as carbamazepine and sodium calproate has no benefit in preventing alcohol withdrawl seizures.

If a seizure occurs, medical assessment is required to exclude other contributing factors (e.g. head injury or electrolyte disturbances).

3.6.2 Delirium tremens

Delirium tremens is a medical emergency that requires hospital treatment in a high dependency unit.

Isolated delirium tremens is rare and delirium occurring in the context of alcohol withdrawal often has multiple causes. Screen for other factors contributing to delirium, in particular:

• subdural haematoma

• head injury

• Wernicke’s encephalopathy

• hepatic encephalopathy

• hypoxia

• sepsis

• metabolic disturbances

• intoxication with or withdrawal from other drugs.

Major psychotic disorders can sometimes mimic this state.

Patients in delirium tremens are mentally disordered, and it is not acceptable to allow them to sign themselves out of hospital. It is often more appropriate to manage them under the provision of the Guardianship and Administration Act 2000 (Qld) rather than the Mental Health Act 2000 (Qld).

Sedation

Sedation with benzodiazepines should be initiated, but is often insufficient to reverse delirium tremens.

If patients will not or cannot take diazepam orally (20 mg hourly, up to 80 mg total dose), use an intravenous midazolam infusion (5 mg bolus, then commence infusion at 2 mg/

hr, titrating rate of infusion against response).

Midazolam infusion must be monitored either by a special nurse or in a high dependency unit.

Intramuscular lorazepam 2 mg is an alternative to midazolam if no high dependency unit is available. Aim to have the patient in a state resembling light sleep, from which he or she can be readily aroused.

Once loaded with benzodiazepines (either by intravenous infusion or oral diazepam), olanzapine 5–10 mg delivered sublingually (wafer) is indicated if the patient is not settled.

Occasionally, patients need doses of diazepam greater than 80 mg to achieve sedation.

However, high doses of benzodiazepines can themselves produce a delirium, so specialist assessment and review is required.

Thiamine

Intravenous thiamine, at least 100 mg three times daily, should be administered.

Supportive management

Supportive management includes:

• intravenous fluid and electrolyte replacement, if required

• restraints in line with local policy, if required

problems.

One-on-one nursing care may be required for a period to re-orient the patient.

Hallucinations

If treatment is required for hallucinations, the drug of first choice is diazepam. Add olanzapine if hallucinations do not respond to diazepam alone.

If olanzapine is required:

• the patient should already be receiving diazepam, which will reduce risks of seizures or dystonic reactions

• the starting dose may be between 5 mg and 10 mg, orally or buccally (wafer)

• if there is no response and no undue side effects, an additional dose may be administered

• doses are ordered as required and should be under constant review

• due to the risk of over-sedation, parenteral diazepam and parenteral olanzapine are not to be given within a short time of each other.

3.6.3 Management of withdrawal with intercurrent illness

Alcohol withdrawal is more difficult to manage in the presence of intercurrent illness. In particular, decompensated liver disease and respiratory disease can make management of withdrawal very difficult.

Loading doses should not be used in patients with severe chronic airflow limitation.

Benzodiazepines need to be used with caution and with close monitoring. If a high-dependency unit is available, an intravenous midazolam infusion is the best way to control withdrawal.

Alternatively, a short-acting benzodiazepine such as temazepam or oxazepam may be used cautiously, with close monitoring of respiration.

when the patient has severe liver disease.

Long-acting benzodiazepines should not be administered to patients who have jaundice, ascites or hepatic encephalopathy. In these instances, oxazepam – which is renally excreted with no active metabolites – may be used with caution.

3.6.4 Pregnancy

A pregnant woman at risk of alcohol withdrawal will be admitted into hospital at any gestation due to the additional risks to her health and that of her foetus at this time, as well as her longer-term health and social support needs.

Risk of alcohol withdrawal can be suspected when a woman reports drinking around six standard drinks or more on most days and/or symptoms of neuroadaptation are reported.

Considerations for pregnant women withdrawing from alcohol

Pregnant women require:

• close observation using a validated withdrawal scale

• nursing and medical care to reduce the risk of complications for them and their unborn babies

• a five-day inpatient stay after the onset of withdrawal

• nutritional intervention including:

– thiamine (continue to term)

– folate replacement (minimum 400 mcg daily and continue to term)

– iron levels assessment

– assessment for other dietary needs.

A reducing diazepam regime may be given to control alcohol withdrawal symptoms.

• Recommend and support ongoing abstinence during pregnancy and lactation.

Pharmacotherapy to maintain abstinence from alcohol cannot be recommended during pregnancy due to insufficient safety data.

Foetal and neonatal effects

Alcohol is a teratogen and the major risk to the foetus from exposure to maternal alcohol use is foetal alcohol syndrome (FAS). In addition, if the woman drinks heavily before the birth, the baby is at risk of neonatal withdrawal.

Onset of withdrawal for the newborn may begin 24–48 hours after birth, depending on the time of the mother’s last drink, and may require management by a specialist neonatal unit.

Babies born to women who have consumed alcohol regularly during pregnancy should be carefully assessed for foetal alcohol spectrum disorders (FASD) by a paediatrician aware of the maternal drinking history.

3.7 Continuing care

Successful withdrawal management should not be seen as an end in itself. All individuals should be encouraged to consider the range of relevant options to help them maintain their abstinence or maintain a more controlled drinking pattern.

For general information on continuing care, see section 2.