From the Guidelines
When evaluating a patient with severe alcohol abuse, it is crucial to obtain a comprehensive history and laboratory workup, prioritizing the assessment of drinking patterns, comorbid substance use, psychiatric conditions, and medical complications of alcoholism, as recommended by the most recent study 1. The history should focus on:
- Drinking patterns (quantity, frequency, duration)
- Last drink
- Previous withdrawal episodes
- Seizures
- Delirium tremens
- Blackouts
- Attempts at sobriety
- Comorbid substance use
- Psychiatric conditions
- Medical complications of alcoholism Physical examination should assess for signs of:
- Intoxication
- Withdrawal
- Malnutrition
- Liver disease
- Neurological abnormalities Laboratory tests should include:
- Complete blood count (looking for macrocytic anemia)
- Comprehensive metabolic panel (liver function tests, electrolytes, glucose)
- Magnesium
- Phosphate
- Blood alcohol level
- Urine toxicology Additional tests to consider include:
- Gamma-glutamyl transferase (GGT)
- Carbohydrate-deficient transferrin (CDT)
- Ammonia levels if encephalopathy is suspected
- Thiamine level Imaging studies like abdominal ultrasound may be indicated to assess for liver disease or pancreatitis, as suggested by 1 and 1. These assessments help guide immediate management of withdrawal, nutritional supplementation (particularly thiamine 100mg IV/IM three times daily initially to prevent Wernicke's encephalopathy), and long-term treatment planning including potential medications like acamprosate, naltrexone, or disulfiram for maintaining sobriety, as discussed in 1 and 1.
From the Research
Important History for Patients with Severe Alcohol Abuse
- A thorough medical history is essential to identify patients at risk for alcohol withdrawal syndrome (AWS) 2
- Patients with a history of alcohol abuse should be assessed for symptoms of AWS, including autonomic hyperactivity, agitation, combativeness, hallucinations, seizures, delirium, and death 3
- A comprehensive review of the patient's medical history, including any previous episodes of AWS, is crucial to guide treatment decisions 4
Laboratory Tests for Patients with Severe Alcohol Abuse
- Laboratory tests, such as liver function tests and electrolyte panels, can help identify patients with severe alcohol abuse and guide treatment decisions 2
- Patients with severe alcohol abuse may require regular monitoring of their laboratory results to prevent complications, such as seizures and delirium tremens 3
- The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) score can be used to assess the severity of AWS and guide treatment decisions 5
Treatment Options for Patients with Severe Alcohol Abuse
- Benzodiazepines, such as diazepam, lorazepam, and chlordiazepoxide, are commonly used to treat AWS 3, 5, 4
- Symptom-triggered treatment with benzodiazepines is the cornerstone of therapy for AWS 2
- Alternative treatments, such as antiepileptics and baclofen, may be considered for patients who are resistant to benzodiazepines or have contraindications to their use 6