JURNAL READING

Pembimbing : dr. Iwan Sys

Indrawanto, Sp.KJ

Antonio Mirijello, Christina D’Angelo, Anna Ferulli, Gabbriele Vassallo,

Mariangela Antonelli, Fabio Caputo, Lorenzo Leggio, Antonio
Gasbarrini, Giovanni Addolorato

Farizky Jati Ananto (20710401011030)

SMF Ilmu Kedokteran Jiwa / Psikiatri RSJ Menur Surabaya

Fakultas Kedokteran Universitas Muhammadiyah Malang
 Introduction
• Alcohol use disorder (AUD) has been estimated to affect
approximately 18 % of the general population’s lifetime
and 5 % of the population annually.
• Moreover, it has been estimated that almost 20 % of
adult patients in emergency rooms (ERs) suffer from
AUD and that the incidence of alcohol withdrawal
syndrome (AWS) in patients admitted to surgical
Intensive Care Units (ICUs) varies from 8 to 40 %, and
seems to be associated with infectious complications
and a higher mortality rate
• AWS represents a clinical condition characterized by
symptoms of autonomic hyperactivity such as agitation,
tremors, irritability, anxiety, hyperreflexia, confusion,
hypertension, tachycardia, fever and diaphoresis.
• AWS usually develops in alcohol dependent patients
within 6–24 h after the abrupt discontinuation or
decrease of alcohol consumption.
• It is a potentially life-threatening condition whose severity
ranges from mild–moderate forms characterized by
tremors, nausea, anxiety and depression, to severe
forms characterized by hallucinations, seizures,
delirium tremens and coma
 Patophysiology
• Acute alcohol ingestion produces CNS
depression secondary to an enhanced
GABAergic neurotransmission and to a
reduced glutamatergic activity.
• The stimulation of GABA receptors and the
inhibition of N-methyl-Daspartate (NMDA)
receptors represent the best known
mechanisms.
• Chronic CNS exposure to alcohol produces adaptive
changes in several neurotransmitter systems, including
GABA, glutamate and norepinephrine pathways in
order to compensate for alcohol-induced destabilization
and restore neurochemical equilibrium
• This adaptive phenomenon results in long-term
reductions in the effects of alcohol in the CNS, i.e.,
tolerance. In particular, changes observed after chronic
alcohol exposure include a reduction in number,
function and sensitivity to GABA of the GABA
receptors (down-regulation) and an increase in
number, sensitivity and affinity for glutamate of NMDA
receptors (up-regulation)
• The abrupt reduction or cessation of alcohol
intake produces an acute imbalance due to both
the acute reduction of GABA activity and the
increase of glutamatergic action, with
consequent hyperexcitability and
development of AWS symptoms, which may
start as early as a few hours after the last
alcohol intake.
• The up-regulation of dopaminergic and
noradrenergic pathways could be responsible for
the development, respectively, of hallucinations
and of autonomic hyperactivity during AWS
• ‘Kindling’ is represented by an increased
neuronal excitability and sensitivity after
repeated episodes of AWS.
• ‘Kindling’ has been proposed to explain
the risk of progression of some patients
from milder to more severe forms of AWS.
Symptoms of AWS
 Delirium Tremens
• DT represents the most severe manifestation
(fourthdegree) of AWS, and is the result of no
treatment or undertreatment of AWS.
• It occurs in approximately 5 % of patients with
AWS. It usually appears 48–72 h after the last
drink, although it could begin up to 10 days later.
• Symptoms normally last 5–7 days.
• DT is characterised by a rapid fluctuation of
consciousness and change in cognition occurring
over a short period of time, accompanied by severe
autonomic symptoms (sweating, nausea,
palpitations and tremor) and psychological
symptoms (i.e., anxiety).
• The typical DT patient shows agitation, hallucinations
and disorientation. The presence of disorientation
differentiates delirium from alcoholic hallucinosis.
Delirium, psychosis, hallucinations, hyperthermia,
malignant hypertension, seizures and coma are common
manifestations of DT
 Diagnosis
• DSM-5 requires the observation of at least
two of the following symptoms: autonomic
hyperactivity (sweating or tachycardia);
increased hand tremor; insomnia; nausea
or vomiting; transient visual, tactile or
auditory hallucinations or illusions;
psychomotor agitation; anxiety; and tonic–
clonic seizures.
• The Clinical Institute Withdrawal Assessment for
Alcohol (CIWA-A) scale has emerged as a
useful tool for assessing severity of AWS,
particularly in the ten-item revised form (CIWA-
Ar).
• Scores of <8 indicate mild withdrawal
• 8–15 indicate moderate withdrawal (marked
autonomic arousal)
• >15 indicate severe withdrawal and are also
predictive of the development of seizures and
delirium.
• Mild AWS is identified by a total score of
≤5;
• moderate AWS by scores of 6–9;
• severe AWS by scores ≥10.
 Treatments
• Non-pharmacological interventions are the
first-line approach and, sometimes, the
only approach required.
• They include frequent reassurance, reality
orientation and nursing care. A quiet room
without dark shadows, noises or other
excessive stimuli (i.e., bright lights) is
recommended
 Conclusions
• AWS represents a potentially life-
threatening medical condition typically
affecting AUD patients abruptly decreasing
or stopping alcohol consumption
• The use of a clinician-administered scale
(CIWA-Ar or Alcohol Withdrawal Scale) is
important to diagnose AWS and start
adequate treatment.
• BZDs represent the gold standard treatment
because of both for their high rate of efficacy
and being the only medications with proven
ability to prevent the complicated forms of AWS
(seizures, DTs)
• While the addictive properties of BZDs limit their
longterm use, the possibility of using other
pharmacological agents effective both for the
treatment of AWS and the subsequent long-term
programme for alcohol relapse prevention
represents an advantage, i.e., carbamazepine,
SMO, baclofen, gabapentin and topiramate
“Betapapun, kesehatan tak ternilai
yang telah dianugerahkan Tuhan
patut kita syukuri dan kita rawat.
Lebih jauh lagi, kita bisa ikut
menjaga hilangnya akal sehat
pada satu generasi berikutnya “