E VIDENCE TO RECOMMENDATIONS

The GDG discussed the difference between preventing seizures, treating a patient during a seizure and preventing recurrent seizures. It was noted that effective treatment of acute alcohol withdrawal will result in the prevention of seizures. As such, a seizure in a patient during treatment can be considered as a treatment failure. The GDG therefore agreed that it was important to emphasise the need to review a patient’s treatment regimen if they develop a seizure as this may be due to a sub-optimal level of initial treatment.

Further discussion revolved around the issues of treating an acute seizure and

preventing further seizures in those patients who present having had a seizure. The GDG noted that the evidence considered was obtained from people not receiving any

treatment for acute alcohol withdrawal but who presented to Accident and Emergency following an initial alcohol withdrawal related seizure. In spite of this, the GDG thought that the evidence could be extrapolated to those patients that have had a seizure on a withdrawal regimen.

It is rare for an alcohol withdrawal seizure not to be self-limiting, so the clinical question had been posed to determine how to manage a patient who has had a seizure.

Specifically, it had been posed to determine if benzodiazepines or anticonvulsants were efficacious in this clinical situation.

The evidence included a low quality meta-analysis with no assessment of individual study quality. The evidence did not report any adverse events or complications associated with lorazepam.

The D’Onofrio43 _{study showed that lorazepam was superior to placebo in preventing} further seizures. It was noted that this study excluded people after enrolment if they required treatment for moderate to severe withdrawal. As such, the GDG recognised significant limitations with the study as it does not reflect the population in the UK that usually needs treatment to prevent recurrent seizures.

The GDG considered it important that the three studies comparing phenytoin with placebo reported no significant differences in the incidence of recurrent seizures. None of the evidence reviewed included people from the young adult and older adult populations.

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2.5.7 R

R11 In people with alcohol withdrawal seizures, consider offering a quick-acting benzodiazepine (such as lorazepamj_{) to reduce the likelihood of further seizures.} R12 If alcohol withdrawal seizures develop in a person during treatment for acute

alcohol withdrawal, review their withdrawal drug regimen. R13 Do not offer phenytoin to treat alcohol withdrawal seizures.

j _{Lorazepam is used in UK clinical practice in the management of alcohol withdrawal seizures. At the time of}

writing (May 2010), lorazepam did not have UK marketing authorisation for this indication. Informed consent should be obtained and documented. In addition, the SPC advises that use in individuals with a history of alcoholism should be avoided (due to increased risk of dependence).

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2.6 A

2.6.1 C

I

Patients who are alcohol dependent and therefore at risk of developing acute alcohol withdrawal (AAW) may have complex needs. They are likely to have experienced health problems leading to frequent attendance at acute hospitals, particularly accident and emergency departments4_{. It would seem both sensible and practical to ensure that when} such patients present, health professionals in this setting have the necessary skills to manage their condition in an effective and timely manner. Such skills include the ability to detect alcohol dependence at an early stage in a presentation, and to accurately assess the severity of, or the risk of developing AAW.

It is recognised that the management of AAW varies according to the expertise available at the point of assessment. Early detection and prompt initiation of treatment is crucial as untreated AAW may progress to delirium tremens, which can be fatal in untreated patients. Death may result from respiratory and cardiovascular collapse or cardiac arrhythmias. As well as reducing mortality, accurate assessment and optimal treatment results in fewer complications, reduces progression to delirium, reduces the course and duration of AAW, and consequently reduces length of stay in hospital.

The scope of this guidance is to provide recommendations for the medical management of AAW. Thus, we need to determine if tools are available to assist in accurate

assessment of the severity of alcohol withdrawal, if these tools are clinically effective, and who is best placed to utilise these tools in the development of effective care pathways.

The dedicated alcohol specialist nurse (ASN) is considered important in assessing patients and enhancing patient compliance and concordance, augmenting medical treatments and co-ordinating aftercare and follow-up. These factors have been demonstrated to be essential components of effective treatment. It is noteworthy that the recently revised version of CIWA-Ar, the CIWA-Ad, has been demonstrated to have good inter-rater reliability for use by nurses, the K-value for the entire AAS scale being 0.6447_.

The clinical question asked, and upon which literature searching was undertaken was:

1) What is the accuracy of a tool and/or clinical judgement for the a) assessment b) monitoring of patients who are alcohol dependent and therefore at risk of developing acute alcohol withdrawal?

2) Does the assessment and monitoring of patients with acute alcohol withdrawal improve patient outcomes?

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2.6.2 C

What is the accuracy of a tool and/or clinical judgement for the a) assessment b)

monitoring of patients

who are alcohol dependent and therefore at risk of