Dr Stephen Stewart and Dr Sharon Swain explain how the NICE guideline on the management of alcohol-related physical complications aims to raise standards of care

  • Almost a quarter of adults drink in a hazardous or harmful way
  • The NICE guideline on the management of alcohol-related physical complications should be read in conjunction with related NICE guidance
  • Admission to hospital for medically assisted acute alcohol withdrawal depends on individual circumstances, including severity of the syndrome and co-morbidities
  • Patients who are dependent on alcohol and are not admitted to hospital should be advised to avoid a sudden reduction in alcohol intake
  • Healthcare professionals who are involved in caring for people in acute alcohol withdrawal should be skilled in the assessment and monitoring of withdrawal symptoms and signs
  • The NICE guideline recommends a symptom-triggered rather than a fixed-dosing prescribing regimen for acute alcohol withdrawal. It is very important that the symptom-triggered regimen is only used for people who are in hospital or where 24-hour assessment and monitoring are available
  • Thiamine should be offered to people at high risk of developing, or with suspected Wernicke’s encephalopathy

In the UK, it is estimated that 24% of adults drink in a hazardous or harmful way.1 Continued hazardous and harmful drinking can result in dependence and tolerance with the risk of withdrawal syndrome on abrupt reduction or cessation; it can also result in damage to almost any organ or system in the body.2

In England in 2007, there were 134,429 items prescribed in primary care settings or NHS hospitals and dispensed in the community for drugs relating to the treatment of alcohol dependence.1 Hazardous and harmful drinkers are commonly encountered among hospital attendees, with 863,300 alcohol-related admissions to hospital in 2007/08, an increase of 69% since 2002/03.1 The cost to the NHS of treating acute and chronic drinking is estimated at up to £2.7 billion a year.3

Remit of the guideline

In June 2010, NICE published its 100th clinical guideline; this focused on the diagnosis and clinical management of alcohol-related physical complications in adults and children (aged over 10 years).2,4 The guideline covers:

  • acute alcohol withdrawal
  • Wernicke’s encephalopathy
  • liver disease
  • acute and chronic pancreatitis.

This guideline is part of a suite of three and should be read in conjunction with the NICE:

  • Public Health Guidance 24 on Alcohol-use disorders: preventing the development of hazardous and harmful drinking5 and
  • Clinical Guideline on Alcohol use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence (expected in February 2011).6

The NICE recommendations are not specific to a setting but many impact directly on primary care. The key recommendations and how they can improve clinical management are discussed below.

Acute alcohol withdrawal can be recognised by tremor, anxiety, and irritability in the 24 hours following the last drink. In severe cases, this can be followed by more marked autonomic overactivity with tachycardia and sweating. This may progress to seizures or hallucinations (delerium tremens).

Acute alcohol withdrawal

Not all people in acute alcohol withdrawal require admission to hospital. Whether someone requires admission for medically assisted acute-alcohol withdrawal depends on factors such as the severity of the syndrome and the person’s co-morbidities. The guideline makes key recommendations in this area and these are summarised in Figure 1 (below).7 They reflect the fact that unplanned admission for medically assisted withdrawal should only be necessary when the withdrawal is severe or likely to become severe.2,4

For people who are alcohol dependent but who have not been admitted to hospital, advice should be offered to avoid a sudden reduction in alcohol intake (due to the risks of severe withdrawal) and information should be given about how to contact local alcohol support services.3,4 The person can then be assessed properly prior to a planned medically assisted withdrawal.

Figure 1: Managing hospital admission for acute alcohol withdrawal7

National Institute for Health and Care Excellence (2010) Quick Reference Guide. Alcohol use disorders: Diagnosis and clinical management of alcohol-related physical complications. London: NICE. Reproduced with permission. Available from www.nice.org.uk/guidance/CG100

Assessment and monitoring

The recommendations on assessment and monitoring focus on the importance of well-trained staff who can respond quickly when needed. Staff should be able to assess competently the severity of withdrawal in hospital or in the community. This may be with the aid of a recommended tool such as the Clinical Institute Withdrawal Assessment— Alcohol, revised (CIWA–Ar) scale.8

Treatment of withdrawal should be based on locally agreed protocols, and if pharmacotherapy is required, it should be with one of the drugs recommended below.2,4

The key recommendations on the management of acute alcohol withdrawal are summarised in Table 1. Importantly, clomethiazole is not recommended for use in the community.2,4

Table 1: Management of acute alcohol withdrawal2,4
Presentation Management
Acute alcohol withdrawal
  • Consider offering a benzodiazepine or carbamazepine
  • Clomethiazole may be offered as an alternative to a benzodiazepine or carbamazepine; however, this agent should be used with caution, only in inpatient settings, and according to the summary of product characteristics
  • Provide the patient with information about how to contact local alcohol support services
Delirium tremens
  • Offer oral lorazepam as first-line treatment
  • If symptoms persist or oral medication is declined, give parenteral lorazepam, haloperidol, or olanzapine
  • If delirium tremens develops in a patient during treatment for acute alcohol withdrawal, review their withdrawal drug regimen
Alcohol-withdrawal seizures
  • Offer a quick-acting benzodiazepine (such as lorazepam) to reduce the likelihood of further seizures
  • If alcohol withdrawal seizures develop in a person during treatment for acute alcohol withdrawal, review their drug regimen for withdrawal
  • Do not offer phenytoin to treat alcohol withdrawal seizures

Symptom-triggered versus fixed-dosing regimen

One of the more controversial decisions of the Guideline Development Group (GDG) was to advise a symptom-triggered regimen rather than fixed dosing for pharmacological treatment of patients with acute alcohol withdrawal.2,4 With a symptom-triggered regimen, the patient is regularly assessed and monitored using clinical experience and questioning alone, or with the help of a designated questionnaire such as the CIWA-Ar.8 Drugs are withheld if there are no symptoms. While the symptom-triggered regimen is more labour-intensive, it facilitates shorter hospital stays and less prescribing of medicines. The caveat is the requirement for 24-hour assessment and monitoring. As such, it is likely that most community settings will continue to use the fixed-dosing regimen.

Wernicke’s encephalopathy

Wernicke-Korsakoff syndrome develops in people who drink in a hazardous or harmful way and are thiamine deficient. Wernicke’s encephalopathy comprises a triad of global confusion, eye signs, and ataxia.2 The NICE guideline provides recommendations on who should receive prophylaxis to prevent this condition and who should receive treatment to prevent the progression to Korsakoff’s psychosis.2,4 Korsakoff’s psychosis is an amnesic state in which there is profound impairment in both retrograde and anterograde memory but relative preservation of other intellectual abilities; confabulation may be a feature. Korsakoff’s psychosis generally develops after an acute episode of Wernicke’s encephalopathy.2

In addition to alcohol intake, malnourishment and liver dysfunction may predispose harmful or dependent drinkers to thiamine deficiency. People with a low risk of developing Wernicke’s encephalopathy include those who are alcohol dependent but otherwise eating a normal diet and with no other alcohol-related problem.2 The guideline makes a number of important recommendations for the prevention and management of Wernicke’s encephalopathy. Many of these are relevant in primary care and should reduce the incidence of this devastating condition.

Thiamine should be offered to people at high risk of developing, or with suspected, Wernicke’s encephalopathy. This agent should be given in doses toward the upper end of the range provided in the British national formulary.9 Thiamine should be given orally or parenterally depending on patient circumstances.

Prophylaxis and treatment
Harmful or dependent drinkers should be offered prophylactic oral thiamine:2,4

  • if they are malnourished or at risk of malnourishment or
  • if they have decompensated liver disease or
  • if they are in acute withdrawal or
  • before and during a planned medically assisted alcohol withdrawal.

Harmful or dependent drinkers should be offered prophylactic parenteral thiamine followed by oral thiamine:2,4

  • if they are malnourished or at risk of malnourishment or
  • if they have decompensated liver disease

and in addition

  • they attend an emergency department or
  • are admitted to hospital with an acute illness or injury.

Parenteral thiamine should be given for a minimum of 5 days if Wernicke’s encephalopathy is suspected (unless this condition can be excluded). This should be followed by oral thiamine treatment. A high level of suspicion should be maintained for the possibility of Wernicke’s encephalopathy, especially if the person is intoxicated.

Alcohol-related liver disease

The diagnosis, staging, and treatment of alcohol-related liver disease can be challenging, particularly in the person who continues to drink. The GDG recommended that abnormal liver function in a hazardous drinker should not be assumed to be related to alcohol, and other causes should be sought. When a diagnosis of alcohol-related disease is suspected, it should be confirmed by a specialist as this may often lead on to a liver biopsy for disease staging.2,4

The specific indications for liver transplantation were not reviewed by the NICE guideline and the reader is directed to the appropriate national guideline.10 However, the indications for referral for assessment for liver transplantation were considered. A key recommendation is to refer patients with decompensated liver disease (jaundice, ascites, or encephalopathy) if they:2,4

  • still have decompensated liver disease after best management and 3 months’ abstinence from alcohol and
  • are otherwise suitable candidates for liver transplantation according to national guidelines.

The remaining recommendations focus on inpatient care of acute alcohol-related hepatitis and cover the role of liver biopsy, corticosteroid treatment, and nutritional support.2,4

Chronic alcohol-related pancreatitis

Chronic pancreatitis should be suspected in a hazardous or harmful drinker with central abdominal pain, particularly when this pain is coupled with malabsorbtion/maldigestion and/or diabetes.

It is likely that there are many patients with pain from chronic alcohol-related pancreatitis who are candidates for surgical or non-surgical therapies, but who are not referred to specialist centres. To address this, the NICE guideline recommends that these patients should be referred to a specialist centre for multidisciplinary assessment. In people with a history and symptoms suggestive of chronic pancreatitis it is reasonable to consider computed tomography as a first-line investigation.2,4

Pancreatic enzyme supplements should be offered to people with chronic alcohol-related pancreatitis who have symptoms of steatorrhoea or poor nutritional status as a result of exocrine pancreatic insufficiency. They should not be given to people with chronic alcohol-related pancreatitis if pain is their only symptom.

Implementation

The GDG believes that the implementation of these recommendations will significantly improve patient care. For primary care there are several challenges. The first is the recognition of alcohol withdrawal and the assessment of its severity. This is critical to determining which patients need admission and which need referral to alcohol services. Secondly, there is the detection and initial assessment of end-organ damage such as in the liver or pancreas. Increased detection of these problems leads to two benefits: the conditions can be treated as per recommendations (such as the pain of chronic pancreatitis), but also, the patient can undergo further assessment and treatment for their hazardous or harmful drinking. Thirdly, there is the appropriate assessment, prophylaxis, and referral for treatment of Wernicke’s encephalopathy. This involves recognition of those at risk and a low index of suspicion for the condition itself.

Implementation will require primary care healthcare workers to be aware of the frequency of alcohol problems and be vigilant to the presentations. Hopefully the publication of the NICE guideline will help to further raise awareness.

Future research

The NICE GDG made a number of research recommendations in the areas below.3,4

Admission to hospital for acute alcohol withdrawal
What are the clinical and cost effectiveness of admitting people who attend hospital in mild or moderate acute alcohol withdrawal for unplanned medically assisted alcohol withdrawal? How does this compare with no admission and a planned medically assisted alcohol withdrawal with regard to the outcome of long-term abstinence?

Dosing regimens for acute alcohol withdrawal
What are the safety and efficacy of symptom-triggered, fixed-dosing, and front-loading regimens for the management of acute alcohol withdrawal?

Drugs for the management of alcohol withdrawal
What are the efficacy and cost effectiveness of clomethiazole compared with chlordiazepoxide or carbamazepine or benzodiazepines for the treatment of acute alcohol withdrawal with regard to the outcomes of withdrawal severity, risk of seizures, risk of delirium tremens, length of treatment, and patient satisfaction?

Assessment and monitoring
What are the clinical and cost effectiveness of interventions delivered in an acute hospital setting by an alcohol specialist nurse compared with those managed through acute hospital setting with no input from a specialist nurse?

Wernicke’s encephalopathy
What are the clinical and cost effectiveness of the use of parenteral versus oral thiamine in preventing the first onset of Wernicke’s encephalopathy in people undergoing medically assisted alcohol withdrawal?

Summary

The NICE recommendations on the management of alcohol-related physical complications are not specific to a clinical setting. Some of the recommendations produced for the guideline are relevant mainly to hospital care, while others are more relevant to primary care. Ideally, healthcare professionals caring for these patients should work to nationally agreed standards throughout primary, secondary, and tertiary care. We are a long way from that, but hopefully the NICE guideline can move us a step closer to that goal.

Acknowledgments

The authors would like to thank the other members of the GDG: Adam Bakker, Adrian Boyle, Joss Bray, Annabelle Bundle, Eilish Gilvarry, Georgina Kirwin, Taryn Krause, Philippe Laramee, Anne McCune, Marsha Morgan, Gerri Mortimore, Lynn Owens, Stephen Pereira, Alison Richards, Anthony Rudd, Colin Standfield, Robin Touquet, Olivier Van den Broucke. Co-opted experts: Tom Kurzawinski and Allan Thomson.

This work was undertaken by Stephen Stewart and Sharon Swain who received funding from the National Institute for Health and Care Excellence. The views expressed in this publication are those of the authors and not necessarily those of the Institute.

NICE implementation tools

NICE has developed the following tools to support implementation of Clinical Guideline 100 on Alcohol use disorders: Diagnosis and clinical management of alcohol-related physical complications. They are now available to download from the NICE website: www.nice.org.uk.

Algorithms

The algorithms cover the management of acute alcohol-related hepatitis and acute alcohol withdrawal.

Audit support

Audit support has been developed to support the implementation of the NICE guideline on the diagnosis and clinical management of alcohol-related physical complications. The aim is to help NHS organisations with a baseline assessment and to assist with the audit process, thereby helping to ensure that practice is in line with the NICE recommendations. The audit support is based on the key recommendations of the guidance and includes criteria and data collection tools.

Baseline assessment tool

The baseline assessment is an Excel spreadsheet that can be used by organisations to identify if they are in line with practice recommended in NICE guidance and to help them plan activity that will help them meet the recommendations.

Costing tools

National cost reports and local cost templates for the guideline have been produced:

  • Costing reports are estimates of the national cost impact arising from implementation based on assumptions about current practice, and predictions of how it might change following implementation of the guideline
  • Costing templates are spreadsheets that allow individual NHS organisations and local health economies to estimate the costs of implementation taking into account local variation from the national estimates, and they quickly assess the impact the guideline may have on local budgets.

Slide set

The slides are aimed at supporting organisations to raise awareness of the guideline and resulting implementation issues at a local level, and can be edited to cater for local audiences. This information does not supersede or replace the guidance itself.


References

  1. The NHS Information Centre. Statistics on alcohol: England, 2009. London: The Health and Social Care Information Centre, 2009. Available at: www.ic.nhs.uk/statistics-and-data-collections/health-and-lifestyles/alcohol/statistics-on-alcohol-england-2009-%5Bns%5D
  2. National Clinical Guideline Centre for Acute and Chronic Conditions. Alcohol use disorders: Diagnosis and clinical management of alcohol-related physical complications. London: RCP, 2010.
  3. Department of Health. The cost of alcohol harm to the NHS in England: An update to the Cabinet Office (2003) study. London: DH, 2008. Available at: www.dh.gov.uk/en/Consultations/Liveconsultations/DH_086412?IdcService=GET_FILE&dID=169373&Rendition=Web
  4. National Institute for Health and Care Excellence. Alcohol use disorders: Diagnosis and clinical management of alcohol-related physical complications. Clinical Guideline 100. London: NICE, 2010. Available at: www.nice.org.uk/guidance/CG100
  5. National Institute for Health and Care Excellence. Alcohol use disorders: preventing the development of hazardous and harmful drinking (public health guideline PH24). London: NICE, 2010. Available from www.nice.org.uk/guidance/PH24
  6. National Institute for Health and Care Excellence. Alcohol use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. (publication expected February 2011). www.nice.org.uk/guidance/CG/Wave17/1
  7. National Institute for Health and Care Excellence. Alcohol use disorders: Diagnosis and clinical management of alcohol-related physical complications. Quick Reference Guide. London: NICE, 2010. Available at: www.nice.org.uk/guidance/CG100
  8. Sullivan J, Sykora K, Schneiderman J et al. Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). Br J Addict 1989; 84 (11): 1353–1357.
  9. British National Formulary. BNF 59. London: BMJ Group and Pharmaceutical Press, Mar 2010.
  10. Liver Advisory Group. Liver Advisory Group alcohol guidelines. 2005. Available at: www.uktransplant.org.uk/ukt/about_transplants/organ_allocation/pdf/liver_advisory_group_alcohol_guidelines-november_2005.pdf G
  • Physical complications of alcohol-related disorders are common reasons for hospital admission
  • Commissioners should agree local protocols for detoxification and for admission for acute withdrawal
  • Admission for some symptoms of withdrawal could be reduced if adequate community alcohol services are in place to support community management
  • Patients with alcohol-related liver disease or pancreatitis should be referred to an appropriate specialist
  • The algorithms in the NICE guideline form a useful basis for local care pathways—education for primary care healthcare professionals in the use of these may be necessary