What treatment should be pursued for a 50-year-old man with chronic alcohol use disorder presenting with confusion, tachycardia, normotension, normothermia, mild hyperglycemia, abdominal distension, and asterixis?

From the Guidelines

The treatment that should be pursued for this patient is lactulose, as the clinical presentation is most consistent with hepatic encephalopathy. This 50-year-old man with chronic alcohol use disorder is presenting with signs of hepatic encephalopathy, including confusion and asterixis (the alternating flexion and extension of hands when arms are outstretched) 1. The physical finding of a distended abdomen that is dull to percussion suggests ascites, which is common in advanced liver disease. Lactulose is the first-line treatment for hepatic encephalopathy as it works by reducing ammonia levels in the blood, acting as a non-absorbable disaccharide that acidifies the colon, trapping ammonia as ammonium which cannot be absorbed, and also has a cathartic effect that helps eliminate nitrogen-containing compounds from the intestines 1. The typical starting dose is 25-30 mL orally every 1-2 hours until bowel movements occur, then adjusted to achieve 2-3 soft bowel movements daily. While thiamine is important in alcoholic patients to prevent Wernicke's encephalopathy, the clinical presentation here is more consistent with hepatic encephalopathy rather than thiamine deficiency, making lactulose the more appropriate immediate intervention. Additionally, benzodiazepines, such as lorazepam, may be considered for the management of alcohol withdrawal symptoms, but the primary concern in this case is the treatment of hepatic encephalopathy 1. It is also important to note that the patient's alcohol use disorder should be addressed, and abstinence is a crucial component of treatment, as it can help improve liver function and reduce the risk of further complications 1.

Some key points to consider in the management of this patient include:

• Lactulose is the first-line treatment for hepatic encephalopathy
• Benzodiazepines, such as lorazepam, may be considered for the management of alcohol withdrawal symptoms
• Thiamine is important in alcoholic patients to prevent Wernicke's encephalopathy, but the clinical presentation here is more consistent with hepatic encephalopathy
• Abstinence from alcohol is a crucial component of treatment
• Regular monitoring of the patient's condition and adjustment of treatment as needed is essential to ensure the best possible outcome.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Treatment Approach

The patient's presentation suggests Wernicke's encephalopathy, a condition often associated with thiamine deficiency in individuals with chronic alcohol use disorder. The key features of Wernicke's encephalopathy include mental status changes, oculomotor abnormalities, and ataxia, which are partially present in this patient.

Recommended Treatment

Based on the provided evidence, the recommended treatment approach includes:

• Administration of thiamine to address the potential thiamine deficiency and prevent progression to Wernicke-Korsakoff syndrome 2, 3, 4, 5, 6.
• The route and dosage of thiamine remain controversial, but parenteral or intramuscular administration is recommended, with doses ranging from 100 to 300 mg 2, 4, 6.
• Some studies suggest that high-dose thiamine may not be more effective than lower doses, and patient-specific treatment should be considered 3.
• Additionally, addressing magnesium deficiency is crucial, as it can contribute to the development of Wernicke's encephalopathy 6.

Treatment Options

Considering the patient's presentation and the recommended treatment approach, the most appropriate treatment option would be:

• Dextrose and thiamine administration, as it addresses the potential thiamine deficiency and provides glucose for energy metabolism.

Rationale

The rationale for this treatment option is based on the evidence that thiamine deficiency is a common cause of Wernicke's encephalopathy in individuals with chronic alcohol use disorder, and prompt treatment with thiamine can prevent irreversible neurological damage 2, 5, 6. The administration of dextrose is also important to provide energy for the brain and prevent further metabolic disturbances.