Edited by Hannah Stephens, Independent Prescriber - Substance Misuse Services
Oral ethanol prescribing for alcohol withdrawal syndrome: initial findings and future directions following implementation within a United Kingdom National Health Service setting
PubMed
This retrospective observational study explores the potential benefits of ethanol vs benzodiazepines for the treatment of acute alcohol withdrawal within a UK NHS hospital. The pilot intervention focused on emergency presentations due to alcohol withdrawal syndrome, utilising acute ethanol administration to reduce the need for unplanned admission. Results demonstrated a reduction in unplanned admissions, post-detox representations, cost-savings and high levels of patient satisfaction.
It's recognised that whilst alcohol dependence is associated with increased withdrawal severity, medication requirements and increased likelihood of hospital admission, elective detoxification remains a scarce resource. Some historical studies regarding the use of ethanol in the management of delirium tremens suggest it’s positive effect in mitigating alcohol withdrawal symptoms, with fewer side effects and complications than benzodiazepines.
Patients were eligible for the ethanol pilot if they were known by the hospital-based alcohol care team to have a history of severe alcohol withdrawal symptoms, alcohol-related seizures or delirium tremens, or who had a high risk of developing delirium tremens based on a history of daily alcohol consumption in excess of 30 units per day (8g of alcohol per unit). Absence of contraindications such as acute pancreatitis, haematemesis, severe alcoholic hepatitis, prohibitive polypharmacy and decompensated liver disease, and also failure to respond to standard treatment approaches were considered prior to pilot enrolment. Oral ethanol was prescribed on a symptom triggered basis, sourced as vodka 37.5% alcohol by volume (27ml/unit), diluted 1 unit: 50ml of fruit juice concentrate, with ethanol being handled as a controlled drug. Ethanol was typically prescribed as 2-4 units per dose, based on patient history, clinical presentation and clinician assessment. This was compared to oral diazepam delivered on a symptom-triggered basis, assessed with CIWA-Ar.
Most patients across the treatment groups were male, aged 49-51 years, with higher reported alcohol consumption in the benzodiazepine cohort, but there was no difference in the number of previous alcohol-related presentations between treatment groups. However, differences were identified between treatment groups of patients presenting with primarily alcohol-related conditions such as alcohol withdrawal syndrome, alcohol-related hepatitis and Wernicke’s Encephalopathy, predominantly treated with ethanol, and alcohol-related conditions plus wider comorbidities such as congestive heart failure or community acquired pneumonia, for which benzodiazapines and ethanol were prescribed comparably.
Results showed a significant reduction in the likelihood of hospital admission and a reduction in medication requirements for patients managed with ethanol, however some prescribed ethanol did require co-management with benzodiazepines, and it’s acknowledged that this would increase the likelihood of admission secondary to sedation. Additionally reported seizures post-treatment initiation was significantly lower in the ethanol cohort when compared to those prescribed benzodiazepines. It was also found that the ethanol treatment intervention was modest compared to reported daily alcohol intake, with considerably fewer units required in practice to stabilise patients, which supported discussions with patients to safely maintain reduced alcohol consumption on discharge. It’s noted that by the time data was collated, 24% of the 143 patients who engaged with the pilot had died, however no significant difference in mortality was identified between treatment groups.
Commentary:
Perhaps the most striking evidence presented in this study is the percentage of participants that died by the time of data collation, indicating the risk, complexity and vulnerability of alcohol dependent individuals, and the need to consider novel approaches to acute withdrawal and comorbidity management.
Ethanol prescribing has demonstrated both clinical and therapeutic benefits in the immediate and ongoing interventions to reduce alcohol consumption and subsequent risk. The potential cost-saving within today’s NHS climate can also not be overlooked, nor the benefit of alcohol-care teams in supporting triage and care planning from initial emergency department presentation. For this client group who services have struggled to engage with, it also offers a pathway for acute stabilisation of alcohol withdrawal, enabling alcohol-dependent individuals the opportunity to engage with positive change, even if not yet prepared for, or wanting to achieve abstinence. Discharge planning and responsive community interventions from addiction, health and social care providers could also support prevention of drinking-escalation post-discharge and mitigate against further acute presentations.
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