Version 2 This guideline describes how to manage patients who are showing signs and symptoms of alcohol withdrawal and Wernicke s Encephalopathy.

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1 Title of Guideline (must include the word Guideline (not protocol, policy, procedure etc) Contact Name and Job Title (author) Directorate & Speciality A Guideline for the Management of Acute Alcohol Withdrawal and Wernicke s Encephalopathy in Adults. Azma Malik-Senior Clinical Pharmacist DDT Dr Tanzeel Ansari- Consultant Psychiatrist Digestive Disease & Thoracics (DDT) Date of submission June 2015 Date on which guideline must be reviewed (this should be one to three years) August 2018 Explicit definition of patient group to which it applies (e.g. Applies to all Adult patients at Nottingham inclusion and exclusion criteria, diagnosis) University Hospitals NHS Trust who present with Alcohol Withdrawal and symptoms of Wernicke s Encephalopathy Version 2 Abstract This guideline describes how to manage patients who are showing signs and symptoms of alcohol withdrawal and Wernicke s Encephalopathy. Key Words Statement of the evidence base of the guideline has the guideline been peer reviewed by colleagues? Evidence base: (1-6) 1 NICE Guidance, Royal College Guideline, SIGN (please state which source). 2a meta analysis of randomised controlled trials 2b at least one randomised controlled trial 3a at least one well-designed controlled study without 3b randomisation at least one other type of well-designed quasiexperimental study 4 well designed non-experimental descriptive studies (ie comparative / correlation and case studies) 5 expert committee reports or opinions and / or clinical experiences of respected authorities 6 recommended best practise based on the clinical experience of the guideline developer Consultation Process Alcohol Withdrawal, Wernicke s Encephalopathy, Pabrinex, Chlordiazepoxide Thiamine Multivitamins NICE, 2010a NICE PHE guidelines 24 Alcohol-use disorders: preventing the development of hazardous and harmful drinking. NICE, 2011 CG115 NICE June 2010 CG100 Consultant Psychiatrist Consultant Hepatologist Consultant Gastroenterologist Alcohol Liaison Nurse Senior Pharmacist Emergency Admissions Senior Pharmacist Critical Care 1

2 Drug and Therapeutics Committee Target audience All healthcare staff at NUH involved in the care and the management of a patient with alcohol misuse. This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. 2

3 A Guideline for the Management of Acute Alcohol Withdrawal and Wernicke s Encephalopathy in Adults. It is important to recognise the signs and symptoms that may be displayed when a patient is dependent upon alcohol or in a state of alcohol withdrawal. Failure to identify these signs can result in a reduced patient outcome and increased risk of death. All patients admitted to NUH should be screened for their alcohol use. Please refer all patients who are showing signs of alcohol withdrawal to the Hospital Alcohol and Drug Liaison Team. Referrals can be made by any healthcare professional. See Appendix 1 for how to make referrals to the Hospital Alcohol and Drug Liaison Team (HADLT). 3

4 Acute Alcohol Withdrawal Pathway in Adults Baseline Investigations: U&E s, LFT s, blood glucose, magnesium & phosphate, FBC, clotting screen. Refer to page 5 if suspected Wernickes encephalopathy. All patients with alcohol withdrawal symptoms should be referred to HADLT see appendix 1 Table 1 Does the patient have >3 of the signs/symptoms listed below? Tremor (hands, tongue, eye lids) Raised blood pressure Tachycardia (>100bpm) Increased temperature Sweating (hands, face, forehead) Nausea/Vomiting/dry retching Anxiety YES Irritability Insomnia Hallucinations (auditory/visual) Reduced appetite Desire to drink alcohol Headache Malaise Agitation NO Prescribe oral chlordiazepoxide reducing regime on variable dose section of drug chart. Day Day Day Day Day Day Day Day Time mg 20mg 20mg 10mg 10mg 10mg --- S mg 20mg 10mg 10mg T mg 20mg 10mg 10mg 10mg O mg 20mg 20mg 10mg 10mg 10mg 10mg P Also prescribe on the as required section of drug chart: Oral chlordiazepoxide 20mg up to every hour if needed up to a maximum combined daily dose of 180mg daily. (Please note specialist may increase this to 250mg daily under close supervision.) Closely monitor patient for breakthrough alcohol withdrawal and administer when required chlordiazepoxide accordingly. Chlordiazepoxide should NOT be prescribed on discharge to take home unless advised by specialist HADLT. Caution in patients with respiratory depression/ severe hepatic insufficiency/ chronic psychosis. Continue to monitor the patient for above symptoms every 2-4 hours for the first 48 hours of admission. Offer brief advice on alcohol consumption. Patient can self-refer to community alcohol services See appendix 1 for self-referral advice. Consider prophylaxis Pabrinex - see page 5 Note: anaphylaxis is reported rarely with parenteral Pabrinex resus facilities must be available Prescribe on regular prescription section of drug chart: Pabrinex 2 pairs IV three times a day for up to 5 days (minimum of 9 doses to be given) (Dilute in ml of Sodium Chloride 0.9% and give over 30minutes) After Pabrinex course has been completed prescribe oral: Multivitamins ONE daily and Thiamine 100mg three times a day both for 28 days. (The need to continue will be reviewed in the community.) 4

5 Prevention/Treatment of Wernicke s Encephalopathy Baseline Investigations: U&E s, LFT s, blood glucose, magnesium & phosphate, FBC, clotting screen Note Chlordiazepoxide may or may not be needed in patients with WE. Please discuss with HADLT If >1 of the following signs are identified in addition to poor diet or regular alcohol consumption a diagnosis of Wernicke s Encephalopathy should be presumed until symptoms can be excluded by other diagnosis Table 2 Ataxia* Confusion* Ophthalmoplegia* Nystagmus* Hypothermia Hypotension Memory disturbance Reduced consciousness *Late symptoms of Wernicke s Encephalopathy If the patient has a history of alcohol consumption along with poor diet but does not have any of the signs in tables 1 or 2, prescribe Pabrinex prophylactically. Pabrinex ONE pair IV once daily for up to 5 days (minimum of 3 doses to be given) (Dilute in ml of Sodium Chloride 0.9% and give over 30 minutes) Pabrinex 2 pairs IV three times a day For up to 5 days (minimum of 9 doses to be given) (Dilute in ml of Sodium Chloride 0.9% and give over 30 minutes) Patients taking Vitamin B Compound Strong can continue taking this or it can be substituted with multivitamins if required as appropriate. Followed by oral: Multivitamins ONE daily and Thiamine 100mg three times a day both for 28 days. (The need to continue will be reviewed in the community) Glucose can further deplete thiamine stores precipitating Wernicke s-korsakoff syndrome. Avoid if possible. Alcohol withdrawal syndrome can develop into complicated alcohol withdrawal syndrome or Delirium Tremens (DT). All patients with suspected DT should be referred to HADLT for management advice. For Emergency Control of Acutely Disturbed Adult Patients please see separate guideline. 5

6 Appendix 1 Referring to Hospital Alcohol and Drug Liaison Team (HADLT) Patient admitted/presents with alcohol withdrawal symptoms Initial assessment/triage/clerking completed by ward or clinical area. Patient on LJU, B3 D57 or F21 at QMC Patient on any other ward (QMC or CITY) HADLT attend ward at 8am and liaise with Nurse in Charge. Referrals identified Refer patient to HADLT Patient assessed by member of HADLT HADLT Referrals Telephone Ext: or via hospital switchboard The following information is required: Patient name K Number/NHS Number Date of Birth Ward Referrer s name/position If no answer leave a message with the above details and your call will be responded to within 1-2 hours or the following morning between the hours of 8am and 4pm Monday to Friday. If urgent help is required between 8am -4pm Monday to Friday please call or If urgent help is required outside these hours or at the weekend contact on call at Department of Psychological Medicine (DPM) via hospital switchboard or on ext Self-Referral: Last orders for Nottingham City Resident on or CRI Nottingham County Resident on

7 Appendix 2 Pabrinex HP Vitamin B & C Pabrinex HP Vitamin B & C can be prescribed as Pabrinex. Pabrinex is used for rapid therapy of severe depletion or malabsorption of the water soluble vitamins B and C, particularly in alcoholism, where a severe depletion of thiamine can lead to Wernicke's encephalopathy; after acute infections, post-operatively and in psychiatric states. Also used to maintain levels of vitamin B and C in patients on chronic intermittent haemodialysis Pabrinex contains 5ml ampoules of Pabrinex No 1 and Pabrinex No 2. Each No 1 ampoule contains: 5ml ampoule Thiamine Hydrochloride Riboflavin (as Phosphate Sodium) Pyridoxine Hydrochloride 250mg 4mg 50mg Each No 2 ampoule contains: 5ml ampoule Ascorbic Acid Nicotinamide Anhydrous Glucose 500mg 160mg 1000mg e.g. if 2 pairs of Pabrinex are prescribed that means 2x5ml ampoule of No1 mixed with 2x5ml ampoule of No2 and diluted as directed if 1 pair of Pabrinex is prescribed that means 1x5ml ampoule of No1 mixed with 1x5ml ampoule of No2 and diluted as directed Both 1 pair or 2 pairs can be diluted in ml of Sodium Chloride 0.9% and given over 30 minutes. [Type text] 7

8 Appendix 3 Equality Impact Assessment Report 1. Name of Policy or Service Response to external best practice policy 2. Responsible Manager Azma Malik Senior Pharmacist Digestive Diseases and Thoracics 3. Name of person Completing EIA Azma Malik Senior Pharmacist Digestive Diseases and Thoracics 4. Date EIA Completed 17/08/15 5. Description and Aims of Policy/Service This guideline provides guidance for the management of acute alcohol withdrawal and wernicke s encephalopathy in adults This procedure is required in order to encourage the delivery of excellent clinical practice for patients cared for by Nottingham University Hospitals NHS Trust, based on best evidence and local expertise. The procedure supports the Trust Clinical Effectiveness and Audit Policy. 6. Brief Summary of Research and Relevant Data See evidence base information from front page 7. Methods and Outcome of Consultation Consultant Psychiatrist Hospital Alcohol and Drug Liaison Team (HADLT) Senior Pharmacist Gastroenterology Consultants Comments from the above consultations have been received and incorporated where appropriate. 8

9 8. Results of Initial Screening or Full Equality Impact Assessment: Equality Group Age Gender Race Sexual Orientation Religion or belief Disability Assessment of Impact Dignity and Human Rights Working Patterns Social Deprivation 9. Decisions and/or Recommendations (including supporting rationale) From the information contained in the procedure, and following the initial screening, it is my decision that a full assessment is not required at the present time. 10. Equality Action Plan (if required) N/A 11. Monitoring and Review Arrangements Review August