RESULTADOS ESTIMACIÓN FUNCIÓN DE PRODUCCIÓN EN

The GDG recognised this is a very difficult area in which to produce guidance as each individual is different and the clinical problem is often compounded by social problems. It was emphasised that these clinical decisions must be made with compassion and with the patient’s best interests in mind.

People with a co-incident medical problem requiring admission were excluded from the review as these individuals will be admitted for the co-incident problem and started on a regimen to manage their withdrawal from alcohol.

The majority of the studies collated data retrospectively which raises questions about the accuracy of reporting.

The GDG noted the evidence review did not find that repeated unplanned medically assisted withdrawals from alcohol caused harm. Some low quality studies supported an

31 association, but there were as many studies showing no association. While the kindling hypothesis was not disproved, the group agreed there was not enough clinical evidence in favour of the hypothesis to support a recommendation.

As there were no studies comparing the efficacy of hospital admission for an unplanned medically assisted withdrawal from alcohol with either a planned admission or planned out-patient management it was not possible to make an evidence-based

recommendation regarding the efficacy of unplanned medically assisted withdrawal from alcohol. Nevertheless, consensus opinion based on experience within the group was that unplanned medically assisted withdrawal from alcohol in isolation is rarely an effective long-term treatment for alcohol dependence. It may be the case that patients who have planned to stop drinking and present to general hospitals may have good long-term outcomes with regard to abstinence if the appropriate follow up services focusing on relapse prevention are provided on discharge. At present, however, there is often a delay between discharge and the institution of relapse prevention treatment. It was felt that, on balance, these patients were likely to get better long-term benefits by undergoing a planned withdrawal in an elective manner, organised through addiction services, with the relevant and appropriate follow-up.

As such, the GDG emphasised the need to direct people presenting with withdrawal towards alcohol addiction services and encourage them to undergo planned withdrawal (to be covered in ‘Alcohol use disorders: diagnosis and clinical management of harmful drinking and alcohol dependence’ [NICE clinical guideline in development]). The risks of sudden withdrawal from alcohol should be made clear to the person and advice should be given about how best to engage with the most appropriate local addiction services. Advice about reducing and stopping drinking may be given at this point, but what this advice should be was outside the scope of this guidance. It is important to recognize, however, that we are, by definition, referring to a dependent population in withdrawal and that the most acute concerns are the assessment and management of the acute withdrawal episode. If the patient does not require admission, this will usually involve drinking and then slowly reducing alcohol consumption or undergoing a planned medically assisted withdrawal of alcohol.

The GDG agreed, by expert consensus, that individuals may also need admission due to the severity or predicted severity of the syndrome. More specifically, if a person presents following or in a withdrawal seizure or delirium tremens they should be admitted for medical care. In addition the evidence was examined to identify which factors confer a high risk of the withdrawal episode progressing to either seizure or delirium tremens. Factors increasing the risk of DTs have been investigated 19 and have been identified as:

history of alcohol withdrawal seizures a history of DTs

signs and symptoms of autonomic over-activity with blood ethanol concentration greater than 100mg/100ml

32 The GDG considered that these factors should be used as predictors of a severe

withdrawal episode and accepted as an indication that the person should be admitted for medically assisted withdrawal. While some of these features may not mandate admission if the current withdrawal episode is mild, it was agreed they each have predictive utility in a clinical setting. Without stronger evidence it was not felt

appropriate to give guidance about the severity of autonomic symptoms and BAC that would constitute high risk. This will be dictated by the clinical setting with each of the above predictors being of relevance.

All of the studies reviewed were in adult populations although age was not restricted when undertaking the literature search. As such, the GDG agreed that while the presentation of a young person with alcohol withdrawal is rare it is associated with a unique set of problems and management should always include addressing any underlying long-term psychosocial issues. The GDG agreed that this population is particularly vulnerable and that admission should be considered at a lower threshold in those under 18 and advised in those under 16. The GDG recognises that intoxication is a more common problem than withdrawal in this age group.

No correlation was found between age and the severity of withdrawal: however, it was noted that frail people may be more susceptible to post-discharge injury from falls, slips and the like. The GDG agreed there should be a lower threshold for admission for the medical management of alcohol withdrawal in this population. They recognised that biological is more important than chronological age.

The GDG noted that a person’s level of social support outside the hospital setting can make a considerable difference to the outcome and may impact upon the decision as to whether they will require admission or not.