Benzo/etoh withdrawl in ER setting

[brodaiga]

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If admitting from ER for 1-4 days. Do you prefer to write librium, ativan etc as a standing dose to prevent withdrawl if pt has a history of withdrawl symptoms or do you wait for the vitals to creep up?

 

[michaelrack]

For persons with h/o uncomplicated withdrawal, I prefer low to mid-dose ativan taper (starting at .5-1 mg three to 4 x per day) combined with prn

 

[birchswing]

What determines how a doctor chooses a particular benzodiazepine for withdrawal? You both mentioned Ativan. Is that useful in emergency withdrawal because of its lower half life? And why would it be different from prescribed, long-term benzodiazepine therapy withdrawal, which is usually done with Valium (due to its long half life)? I'm assuming the detox for benzos in an ER setting is due to some sort of overdose. On the other hand, I'm not sure why a high-dose use of a benzodiazepine would require any special type of withdrawal, especially if it were a single incident, as this occurs daily with patients having conscious sedation, who require no withdrawal treatment. It seems, from a lay perspective, that withdrawal would only be needed with chronic use, and if that's the case, why would the withdrawal method be different than for other patients withdrawing from benzodiazepines (such as those on long-term benzodiazepine therapy)?

 

[michaelrack]

What determines how a doctor chooses a particular benzodiazepine for withdrawal? You both mentioned Ativan. Is that useful in emergency withdrawal because of its lower half life? And why would it be different from prescribed, long-term benzodiazepine therapy withdrawal, which is usually done with Valium (due to its long half life)? I'm assuming the detox for benzos in an ER setting is due to some sort of overdose. On the other hand, I'm not sure why a high-dose use of a benzodiazepine would require any special type of withdrawal, especially if it were a single incident, as this occurs daily with patients having conscious sedation, who require no withdrawal treatment. It seems, from a lay perspective, that withdrawal would only be needed with chronic use, and if that's the case, why would the withdrawal method be different than for other patients withdrawing from benzodiazepines (such as those on long-term benzodiazepine therapy)?

choice of benzo depends on provider preference, half life, and metabolism- ativan is often used because it (like oxazepam) is not oxidized (by the liver), only conjugated.

 

[strangeglove]

Standing vs. symptom triggered usually depends on the quality of nursing.


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[vistaril]

If admitting from ER for 1-4 days. Do you prefer to write librium, ativan etc as a standing dose to prevent withdrawl if pt has a history of withdrawl symptoms or do you wait for the vitals to creep up?

it depends on the situation, as well as how symptomatic the pt is on admission.

That said, it takes an iq of about 70 to manage. If an intern is present, it's something he/she should just do and not bother anyone else with.

 

[shan564]

it depends on the situation, as well as how symptomatic the pt is on admission.

That said, it takes an iq of about 70 to manage. If an intern is present, it's something he/she should just do and not bother anyone else with.

Ha... hyperbole aside, I agree with the sentiment. If you can fill out a CIWA sheet, you can probably handle most uncomplicated cases. Although you could probably say the same thing about most uncomplicated cases of depression... "patient is sad, start an SSRI."

 

[gibits]

choice of benzo depends on provider preference, half life, and metabolism- ativan is often used because it (like oxazepam) is not oxidized (by the liver), only conjugated.

This is basically my thought process. If LFTs are elevated then it's Ativan.

 

[shan564]

This is basically my thought process. If LFTs are elevated then it's Ativan.

When I was on IM, my attending once chose to use librium despite significant LFT elevation. He was definitely aware of the fact that librium is metabolized by the liver. I guess their rationale is that it'll only extend the half-life and it'll make the self-tapering more effective. I still don't like the idea, but I guess the IM guys are more comfortable managing the liver than I am.

 

[hamstergang]

When I was on IM, my attending once chose to use librium despite significant LFT elevation. He was definitely aware of the fact that librium is metabolized by the liver. I guess their rationale is that it'll only extend the half-life and it'll make the self-tapering more effective. I still don't like the idea, but I guess the IM guys are more comfortable managing the liver than I am.

Seems like a stupid risk to take to me. I'd think it makes the half-life less predictable, and if the liver worsens you won't be able to get rid of the librium (or active metabolites). Why not use Ativan which would be more predictable? It shouldn't be hard to set up a taper through dosing instead of making the liver do it.

 

[Euthymia]

How common is it to treat etoh withdrawal with gabapentin? I met one resident who wouldn't use benzos because he said it made patients feel too good and encouraged drug seeking behavior.

 

[Shikima]

I wouldn't. Would be considered malpractice, especially if one enters into withdrawl seizures or has another adverse event.

 

[splik]

How common is it to treat etoh withdrawal with gabapentin? I met one resident who wouldn't use benzos because he said it made patients feel too good and encouraged drug seeking behavior.

most alcohol withdrawal is done in medical settings so benzos or barbiturates are used. we sometimes use gabapetin 400mg TID for withdrawal, but this will be for milder states, and there is some evidence you reduce relapse in the immediate period with this.

i have used carbamazepine for alcohol withdrawal, and this works, and also has evidence of preventing withdrawal seizures. if someone has prior withdrawal seizures they are more likely to have further seizures via kindling supposedly and this works well.

depakote has also been used for alcohol withdrawal and also works well.

but for the most part benzos work. phenobarb loading is my go-to for severe withdrawal however.

 

[notdeadyet]

How common is it to treat etoh withdrawal with gabapentin? I met one resident who wouldn't use benzos because he said it made patients feel too good and encouraged drug seeking behavior.

There's good evidence for its use to reduce the anxiety and discomfort of cessation AFTER they've passed the period of autonomic instability. If you're going to treat the anxiety and jitters for someone who is just quit drinking with alcohol, they will be on benzodiazepines for quite a while. Gabapentin is helpful to reduce the cravings that occur because of this while avoiding giving someone a heckuva lot of benzo's they may not need.

 

[michaelrack]

Seems like a stupid risk to take to me.

Wikipedia disagrees with you: http://en.wikipedia.org/wiki/Alcohol_detoxification

Here is a more reputable source recognizing Librium as the gold standard (page 129):
http://www.nta.nhs.uk/uploads/nta_review_of_the_effectiveness_of_treatment_for_alcohol_problems_fullreport_2006_alcohol2.pdf

Personally, I prefer ativan, but I think librium was used more back in the old days

 

[hamstergang]

Wikipedia disagrees with you: http://en.wikipedia.org/wiki/Alcohol_detoxification

Here is a more reputable source recognizing Librium as the gold standard (page 129):
http://www.nta.nhs.uk/uploads/nta_review_of_the_effectiveness_of_treatment_for_alcohol_problems_fullreport_2006_alcohol2.pdf

Personally, I prefer ativan, but I think librium was used more back in the old days

I'm not arguing that Librium isn't the gold standard or shouldn't be our go-to drug. But the part I disagreed with was using Librium "despite significant LFT elevation." I don't see wiki or that pdf make mention of what to use in that situation. Do you have a good source for that? I couldn't find anything in 5 seconds of google searching.

 

[michaelrack]

I'm not arguing that Librium isn't the gold standard or shouldn't be our go-to drug. But the part I disagreed with was using Librium "despite significant LFT elevation." I don't see wiki or that pdf make mention of what to use in that situation. Do you have a good source for that? I couldn't find anything in 5 seconds of google searching.

sorry, I was reading through the posts too fast and missed your point.

 

[michaelrack]

from wikipedia: "Regarding the choice of benzodiazepine:

• Chlordiazepoxide (Librium) is the benzodiazepine of choice in uncomplicated alcohol withdrawal due to its long half-life.[7]
• Lorazepam or diazepam is available as an injection for patients who cannot safely take medications by mouth.
• Lorazepam and oxazepam are indicated in patients with impaired liver function because they are metabolised outside of the liver."

Lorazepam (ativan) is my benzo of choice for etoh withdrawal. I rarely use librium.

 

[hamstergang]

• Lorazepam and oxazepam are indicated in patients with impaired liver function because they are metabolised outside of the liver."

Ah right, somehow missed this bullet.

 

[Shikima]

Librium is good for uncomplicated withdrawls but you have to watch that you don't get behind the 8-ball which is easy using this medication.