What is the treatment for alcoholic acidosis?

Treatment of Alcoholic Acidosis

The treatment of alcoholic acidosis should focus on aggressive fluid resuscitation with intravenous fluids, starting with normal saline followed by a mixture of saline and 5% glucose solution, along with thiamine supplementation, electrolyte repletion, and complete alcohol abstinence. 1

Initial Management

• Fluid Resuscitation:

  • Begin with normal saline IV infusion to correct dehydration
  • Follow with a mixture of saline and 5% glucose solution 1, 2
  • Target correction of fluid deficits and electrolyte abnormalities

• Essential Supplements:

  • Administer thiamine (100-300 mg/day) BEFORE glucose to prevent Wernicke's encephalopathy 1, 3
  • Replace electrolytes as needed:
    • Potassium
    • Phosphorus (critical as levels may drop rapidly during treatment) 4
    • Magnesium

Specific Interventions

• Glucose Administration:

  • Provide glucose (7.0-7.5 g/hr IV) to enhance NADH oxidation and reverse ketoacidosis 4
  • Monitor glucose levels closely as hypoglycemia is common

• Bicarbonate Therapy:

  • Generally not required as acidosis typically resolves with fluid and glucose administration 5
  • Consider only in severe acidemia (pH < 7.1) with hemodynamic instability
  • If needed: 2-5 mEq/kg over 4-8 hours, avoiding full correction in first 24 hours 6

• Nutritional Support:

  • Once stabilized, provide adequate nutrition with:
    • Protein: 1.2-1.5 g/kg/day
    • Calories: 35-40 kcal/kg/day 7, 1
  • Consider enteral nutrition if oral intake is inadequate

Management of Alcohol Withdrawal

• Assess severity using CIWA-Ar score:

  • Mild (≤7): Monitor closely
  • Moderate (8-14): Initiate benzodiazepine treatment
  • Severe (≥15): Aggressive benzodiazepine treatment 1

• Benzodiazepine Selection:

  • Prefer lorazepam in patients with liver disease (1-2 mg orally every 4-6 hours as needed)
  • Maximum daily dose should not exceed 8 mg in cirrhotic patients 1

Long-term Management

• Complete alcohol abstinence is essential 7, 1
• Consider pharmacotherapy for alcohol use disorder:
  • Baclofen (30-60 mg/day) - safest option in liver disease
  • Acamprosate (666 mg three times daily)
  • Naltrexone (50 mg once daily) 1

Important Considerations

• Avoid common pitfalls:

  • Never administer glucose before thiamine
  • Don't routinely use insulin (unless severe, refractory acidosis) 5
  • Calculate both anion gap and osmolal gap (>25 mOsm/kg suggests toxic alcohol ingestion) 5

• Monitor closely for:

  • Electrolyte abnormalities (especially hypophosphatemia during treatment)
  • Hypoglycemia
  • Infections (common in alcoholic patients)
  • Worsening renal function

By following this approach, most cases of alcoholic acidosis resolve within 24-48 hours with appropriate treatment 2, 5.