J Korean Neuropsychiatr Assoc.  2013 Mar;52(2):67-75.

Korean Addiction Treatment Guidelines Series (II): Pharmacological Treatment of Alcohol Withdrawal

Affiliations
  • 1Department of Psychiatry, Konkuk University Chungju Hospital, School of Medicine, Konkuk University, Chungju, Korea. sjs52632@daum.net
  • 2Department of Psychiatry, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea.
  • 3Department of Psychiatry, Addiction Center, Seoul National Hospital, Seoul, Korea.
  • 4Dasarang Central Hospital, Uiwang, Korea.
  • 5Department of Addiction Rehabilitation and Social Welfare, Eulji University, Seoul, Korea.

Abstract


OBJECTIVES
In development of Korean addiction treatment guidelines, the aim of this study was to investigate the experts' consensus regarding current pharmacological practice in treatment of alcohol withdrawal.
METHODS
Using recommendations from foreign clinical guidelines, which were either lacking in evidence or could not be directly applied to Korea, the executive committee developed a questionnaire consisting of 17 questions. Using a nine-point scale, members of the Korean Addiction Psychiatry, who were experts (n=150) with sufficient experience in treatment of alcohol use disorder, were asked to evaluate the appropriateness of each item on the questionnaire. We classified the experts' opinion according to three categories, based on the lowest scores of 6.5 or greater as a first-line/preferred treatment, 3.5-6.5 as a second-line/reasonable treatment, and lower than 3.5 as a third-line/inappropriate treatment. The consensus was determined by chi-square test (p<0.05). Response rate was 70.4% (81/115).
RESULTS
The results of the survey from the experts were as follows: 1) Symptom triggered therapy (STT) was the most appropriate strategy in treatment of alcohol withdrawal (95% CI 7.41-8.04). 2) Prophylactic benzodiazepine was recommended for management of expecting alcohol withdrawal in out-patient-department patients. 3) Among benzodiazepines, lorazepam was the most preferred. 4) For patients with severe withdrawal, lorazepam 7.4 mg/day (95% CI 6.48-8.25, maximum dose=20 mg) was recommended. 5) Risperidone, quetiapine, and haloperidol were the first-line drugs for patients with alcohol withdrawal and combined psychotic symptoms. 6) 127.5 mg (95% CI 111-145) for 2.8 months of prophylactic thiamine and 213.5 mg (95% CI 190-240) for 6.2 months of thiamine for Wernicke-Korsakoff's syndrome were recommended.
CONCLUSION
We hope that these Korean addiction treatment guidelines, added by the Korean experts' consensus, will be helpful in promoting the efficacy of treatment for alcohol withdrawal.

Keyword

Addiction; Guidelines; Alcohol withdrawal; Benzodiazepine; Symptom triggered therapy; Thiamine

MeSH Terms

Benzodiazepines
Consensus
Dibenzothiazepines
Haloperidol
Humans
Korea
Lorazepam
Surveys and Questionnaires
Risperidone
Thiamine
Quetiapine Fumarate
Benzodiazepines
Dibenzothiazepines
Haloperidol
Lorazepam
Risperidone
Thiamine

Figure

  • Fig. 1 RAND Corporation's 9-point scale for rating appropriateness of medical decisions.


Reference

1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 2000. 4th ed, text revision. Washington, DC: American Psychiatric Association;216.
2. Bayard M, McIntyre J, Hill KR, Woodside J Jr. Alcohol withdrawal syndrome. Am Fam Physician. 2004. 69:1443–1450.
3. Kasser C, Geller A, Howell E, Wartenberg A. Detoxification: principles and protocols. Accessed 2008 January 7. American Society of Addiction Medicine;Available from http://www.asam.org/publ/detoxification. htm.
4. Seoul National University College of medicine. The Epidemiological Survey of Psychiatric Illnesses in Korea. 2006. Seoul: Ministry of Health & Welfare;1–15.
5. Kim SG, Shin YC, Lee HK, Lee TG, Gee SW, Lee SG, et al. Addiction Treatment Guidelines Series. Ministry of health & welfare alcohol project supporting committee research paper. 2011. Seoul: Korean academy of addiction psychiatry.
6. University of Sydney. Guidelines for the treatment of alcohol problems. 2009. Sydney: University of Sydney;1–255.
7. Williams D, McBride AJ. The drug treatment of alcohol withdrawal symptoms: a systematic review. Alcohol Alcohol. 1998. 33:103–115.
Article
8. Field MJ, Lohr KN. Guidelines for Clinical Practice: from Development to Use. 1992. Washington, DC: National Academy Press.
9. Cpg.or.kr [homepage on the internet]. Clinical practice guideline for stroke. Seoul: Korean Guideline Clearinghouse;Available from http://cpg.or.kr.
10. Guideline.or.kr [homepage on the internet]. Hypertension treatment guidelines, Depressive disorders treatment guidelines. Seoul: Korean Medical Guideline Information Center;Available from http://www.guideline.or.kr.
11. Kim SY, Kim NS, Shin SS, Kim DW, Jee SM, Lee SJ. Manual for Guideline Adaptation ver 1.0. 2009. Seoul: Korea Centers For Disease Control & Prevention, Clinical research coordinating center, Guidelines supporting center;1–115.
12. Agreetrust.org [homepage on the internet]. Appraisal of Guidelines for Research & Evaluation. Available from http://www.agreetrust.org.
13. Addictionacademy.org [homepage on the internet]. Addiction Treatment Guidelines Series. Available from http://www.addictionacademy.org.
14. Sachs GS, Printz DJ, Kahn DA, Carpenter D, Docherty JP. The Expert Consensus Guideline Series: Medication Treatment of Bipolar Disorder 2000. Postgrad Med. 2000. (Spec No):1–104.
15. Seo JS, Min KJ, Kim W, Seok JH, Bahk WM, Song HC, et al. Korean Medication Algorithm for Depressive Disorder 2006 (I). J Korean Neuropsychiatr Assoc. 2007. 46:453–460.
16. Lange-Asschenfeldt C, Müller MJ, Szegedi A, Anghelescu I, Klawe C, Wetzel H. Symptom-triggered versus standard chlormethiazole treatment of inpatient alcohol withdrawal: clinical implications from a chart analysis. Eur Addict Res. 2003. 9:1–7.
Article
17. Daeppen JB, Gache P, Landry U, Sekera E, Schweizer V, Gloor S, et al. Symptom-triggered vs fixed-schedule doses of benzodiazepine for alcohol withdrawal: a randomized treatment trial. Arch Intern Med. 2002. 162:1117–1121.
Article
18. Hecksel KA, Bostwick JM, Jaeger TM, Cha SS. Inappropriate use of symptom-triggered therapy for alcohol withdrawal in the general hospital. Mayo Clin Proc. 2008. 83:274–279.
Article
19. Lohr RH. Treatment of alcohol withdrawal in hospitalized patients. Mayo Clin Proc. 1995. 70:777–782.
Article
20. Jaeger TM, Lohr RH, Pankratz VS. Symptom-triggered therapy for alcohol withdrawal syndrome in medical inpatients. Mayo Clin Proc. 2001. 76:695–701.
Article
21. Elholm B, Larsen K, Hornnes N, Zierau F, Becker U. Alcohol withdrawal syndrome: symptom-triggered versus fixed-schedule treatment in an outpatient setting. Alcohol Alcohol. 2011. 46:318–323.
Article
22. Prater CD, Miller KE, Zylstra RG. Outpatient detoxification of the addicted or alcoholic patient. Am Fam Physician. 1999. 60:1175–1183.
23. Myrick H, Anton RF. Treatment of alcohol withdrawal. Alcohol Health Res World. 1998. 22:38–43.
24. Bayard M, McIntyre J, Hill KR, Woodside J Jr. Alcohol withdrawal syndrome. Am Fam Physician. 2004. 69:1443–1450.
25. Mayo-Smith MF. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal. Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline. JAMA. 1997. 278:144–151.
Article
26. Mayo-Smith MF, Beecher LH, Fischer TL, Gorelick DA, Guillaume JL, Hill A, et al. Management of alcohol withdrawal delirium. An evidence-based practice guideline. Arch Intern Med. 2004. 164:1405–1412.
Article
27. Lingford-Hughes AR, Welch S, Nutt DJ. British Association for Psychopharmacology. Evidence-based guidelines for the pharmacological management of substance misuse, addiction and comorbidity: recommendations from the British Association for Psychopharmacology. J Psychopharmacol. 2004. 18:293–335.
Article
28. Sullivan JT, Swift RM, Lewis DC. Benzodiazepine requirements during alcohol withdrawal syndrome: clinical implications of using a standardized withdrawal scale. J Clin Psychopharmacol. 1991. 11:291–295.
29. Holbrook AM, Crowther R, Lotter A, Cheng C, King D. Diagnosis and management of acute alcohol withdrawal. CMAJ. 1999. 160:675–680.
30. Work Group on Substance Use Disorders. Kleber HD, Weiss RD, Anton RF, Rounsaville BJ, George TP, et al. Treatment of patients with substance use disorders, second edition. American Psychiatic Association. Am J Psychiatry. 2006. 163:8 Suppl. 5–82.
31. National Clinical Guideline Centre. Alcohol-Use Disorders: Diagnosis and Clinical Management of Alcohol-Related Physical Complications. 2010. London: NICE clinical guideline;1–30.
32. Day E, Bentham P, Callaghan R, Kuruvilla T, George S. Thiamine for Wernicke-Korsakoff Syndrome in people at risk from alcohol abuse. Cochrane Database Syst Rev. 2004. CD004033.
Article
33. Sechi G, Serra A. Wernicke's encephalopathy: new clinical settings and recent advances in diagnosis and management. Lancet Neurol. 2007. 6:442–455.
Article
34. Lee SJ, Lee SY, Ha RY, Kim ES, Jung YC, Namkoong K. Screening and treating Wernicke's encephalopathy among alcoholic patients in a university hospital. J Korean Neuropsychiatr Assoc. 2011. 50:323–328.
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