And delirium tremens

A score of more than 15 corresponds to severe withdrawal and at increased risk of seizures and delirium tremens... 

Chronic alcohol drinkers, when forced to reduce or discontinue alcohol, experience a withdrawal syndrome, which indicates the existence of physical dependence. Alcohol withdrawal symptoms classically consist of hyperexcitability in mild cases and seizures, toxic psychosis, and delirium tremens in severe ones. The dose, rate, and duration of alcohol consumption determine the intensity of the withdrawal syndrome. When consumption has been very high, merely reducing the rate of consumption may lead to signs of withdrawal. 

Systematic reviews A systematic review has been conducted to evaluate the efficacy and safety of carbamazepine and oxcarbazepine in treatment of alcohol withdrawal syndrome [108 ]. The authors concluded that trials have provided inconclusive evidence of the efficacy of carbamazepine in preventing alcohol withdrawal seizures and delirium tremens in comparison with benzodiazepines, which remain the primary treatment of moderate-to-severe alcohol withdrawal syndrome. Adverse reactions were not a major problem. 

Some problems should never be managed in psychiatric units - and delirium tremens (DTs) is one of them (Box 77.1). Mortality rates are 5-35%, but higher without treatment or with comorbid physical illness. Consider Dlls whenever assessing a recent-onset (<1 week) delirium, especially where alcohol intake may have been suddenly stopped or reduced, e.g. by hospital admission. 

Paraldehyde, a miscellaneous sedative and hypnotic, may be used to treat delirium tremens and other psychiatric conditions. In addition, some barbiturates are used as anticonvulsants (see Chap. 28). 

The energy substrates are contraindicated in patients with hypersensitivity to any component of the solution. Dextrose solutions are contraindicated in patients with diabetic coma with excessively high blood sugar. Concentrated dextrose solutions are contraindicated in patients with increased intracranial pressure, delirium tremens (if patient is dehydrated), hepatic coma, or glucose-galactose malabsorption syndrome Alcohol dextrose solutions are contraindicated in patients with epilepsy, urinary tract infections, alcoholism, and diabetic coma... 

The onset of GHB withdrawal symptoms typically begins 1—5 hours after the last dose initial symptoms include anxiety, tremor, tachycardia, nausea, and insomnia (Table 7—1). Untreated, the symptoms may progress within 24 hours to a more severe pattern that is similar to delirium tremens, with dys-... 

This is the most commonly observed syndrome, and as the name denotes, is not complicated by seizures, delirium tremens (DTs),... 

Gorwood, P., Limosin, F., Batel, P., Hamon, M., Ades, J., and Boni, C., The A9 allele of the dopamine transporter gene is associated with delirium tremens and alcohol-withdrawal seizure, Biol. Psychiatry, 53, 85, 2003. 

Delirium tremens The most severe sign of alcohol withdrawal characterised by hallucinations and paranoia ( delirium ), marked tremor and convulsions ( tremens ). 

Delirium tremens (the D.T.s ) resulting from alcohol withdrawal is slightly different in that it is usually preceded by the shakes, convulsions and occasionally by alcoholic hallucinosis - characterized by accusatory auditory hallucinations. As observed 60 years ago by Maurice Victor, an expert on alcohol problems, delirium tremens usually does not appear until day 3 or 4 following abrupt withdrawal from alcohol. The patient is generally malnourished and grossly deficient in vitamin Bj (thiamine) as the result of a diet consisting of little but alcohol. This deficiency ftirther compromises mental function. 

Side effects of benzodiazepines include drowsiness and reduced respiratory function. In patients who are severely medically ill, especially those with lung disease, this side effect can be problematic. However, benzodiazepines are much safer in this regard than their predecessors, the barbiturates, and untreated delirium tremens, the most severe form of alcohol withdrawal, can be fatal. 

Qomethiazole can also be effective for controlling status epilepticus, but is used mainly to treat agitated states, especially alcoholic delirium tremens and associated seizures. 

IR concentrated oral solution and tablets/suppositories - Respiratory insufficiency or depression severe CNS depression attack of bronchial asthma heart failure secondary to chronic lung disease cardiac arrhythmias increased intracranial or CSF pressure head injuries brain tumor acute alcoholism delirium tremens convulsive disorders after biliary tract surgery suspected surgical abdomen surgical anastomosis concomitantly with MAOIs or within 14 days of such treatment paralytic ileus. 

Acute abdominal conditions Narcotics may obscure diagnosis or clinical course. Do not give SR morphine to patients with Gl obstruction, particularly paralytic ileus, as there is a risk of the product remaining in the stomach for an extended period and the subsequent release of a bolus of morphine when normal gut motility is restored. Special risk patients Exercise caution in elderly and debilitated patients and in those suffering from conditions accompanied by hypoxia or hypercapnia when even moderate therapeutic doses may dangerously decrease pulmonary ventilation. Also exercise caution in patients sensitive to CNS depressants, including those with cardiovascular disease myxedema convulsive disorders increased ocular pressure acute alcoholism delirium tremens cerebral arteriosclerosis ulcerative... 

Acute alcohol withdrawal For the symptomatic relief of acute alcohol withdrawal (clorazepate, chlordiazepoxide, oxazepam) may be useful in symptomatic relief of acute agitation, tremor, impending or acute delirium, tremens, and hallucinosis (diazepam). 

The withdrawal syndrome from ethanol includes anxiety, insomnia, possibly convulsions and visual hallucinations (delirium tremens - the Dts). It is treated or better still prevented by a calm environment, adequate (but not excessive) hydration, and careful monitoring, with the added use of anticon-vulsive/sedative agents, mainly benzodiazepines to prevent or treat convulsions. The preventive effects of benzodiazepines on withdrawal morbidity has been clearly demonstrated. There do not seem to be major differences between benzodiazepines, such as chlordiazepoxide or diazepam or others. Because of the abuse potential in these highly susceptible patients, these should be rapidly weaned, and proper prevention of relapse instituted. Other drugs such as meprobamate and clomethiazole (Hemineurin) are commonly used in some countries. The effectiveness... 

It is indicated in wet beriberi, dry beriberi, Wernicke s encephalopathy, prophylaxis of thiamine deficiency, hyperemesis gravidarum, Korsakoff s syndrome, chronic alcoholics, multiple neuritis, toxic and confusional states, delirium tremens and anorexia nervosa. 

Knowing the differential pharmacokinetics for a class of drugs allows the clinician to choose specific members to either achieve a faster onset or a delayed offset of action (13, 14, 17, 18). For example, lorazepam is rapidly absorbed from the gastrointestinal tract into the systemic circulation and from there distributed into the brain. In contrast, oxazepam, the most polar BZD, is slowly absorbed from the gastrointestinal tract. Even after oxazepam is in the systemic circulation, it slowly enters tissue compartments, including the brain, during the distribution phase. Unlike lorazepam, oxazepam is not available in either the intramuscular or intravenous formulations. Thus, lorazepam would be preferable to achieve acute control of alcohol withdrawal (e.g., delirium tremens), whereas oxazepam would better stabilize a dependency-prone patient on sedative-hypnotics, because it does not cause the euphoria seen with the more rapidly absorbed members of this class. 

Withdrawal syndrome, which may include tremors, hallucinosis, seizures, and delirium (e.g., delirium tremens)... 

Withdrawal delirium (delirium tremens), which usually appears 1 to 4 days after abstinence and peaks at about 72 to 96 hours. The mortality rate may be as high as 15% if serious complicating medical problems are also present. Clinical signs and symptoms include profound confusion, illusions, delusions, vivid hallucinations, agitation, insomnia, and autonomic hyperactivity. Death results from infection, cardiac arrhythmias, fluid and electrolyte abnormalities, or suicide (e.g., in response to hallucinations, illusions, or delusions). 

The main drugs in this section are the barbiturates which can be considered as dry drink , and the withdrawal effects are very similar to the withdrawal from alcohol. Full-blown delirium tremens and epileptic fits can be observed and will need, usually, in-patient management and close supervision and sedation. 

Long-acting drugs such as chlordiazepoxide and diazepam and, to a lesser extent, phenobarbital are administered in progressively decreasing doses to patients during withdrawal from physiologic dependence on ethanol or other sedative-hypnotics. Parenteral lorazepam is used to suppress the symptoms of delirium tremens. 

---