NHS Greater Glasgow & Clyde Area Drug and Therapeutics Committee
Greater Glasgow and Clyde Medicines
Medicines Update

GMAWS - Updated Alcohol Withdrawal Recommendations

UPDATED ALCOHOL WITHDRAWAL RECOMMENDATIONS

Summary of Key Changes

  • New Pabrinex® prescription recommendations for patients ‘at risk’ of Wernicke’s Encephalopathy

  • Oral Thiamine to be given as 50mg four times a day

  • Confirmation of alcohol withdrawal before treatment

  • Identification of patients for whom standard treatment of alcohol withdrawal may be inappropriate

  • Stricter indications for Fixed-dose treatment

  • Guidance for more effective reduction of Fixed-dose treatments

  • Senior medical review necessary in severe cases requiring high dose benzodiazepine treatment 

The Glasgow Modified Alcohol Withdrawal Score (GMAWS) was first introduced to GGC in 2010 with the aim to streamline the management of alcohol withdrawal in the many clinical environments this condition can present. Early recognition and treatment are associated with a reduction in both episodes of aggression and length of hospital stay. With increasing experience, the guidance has been reviewed and updated.  The Full Guideline is available on StaffNet and this section has also been updated within the GGC Adult Therapeutics Handbook.

Here is a summary of the key modifications:

  1. Confirming Alcohol Withdrawal: Some patients who clearly did not have alcohol withdrawal were being managed with GMAWS. There are several causes of confusion or agitation in patients who take alcohol to excess. Therefore on the front page of the guideline there is a strong recommendation that alternative diagnoses be considered particularly if it is 5 or more days since the patient is believed to have taken any alcohol. This should reduce the inappropriate use of an alcohol withdrawal score for patients with alternative diagnoses.

  2. Recognition of Exceptional Patient Groups: The treatment of alcohol withdrawal in patients with other illnesses is challenging with potential risk of harm from high dose diazepam. The importance of recognising such patients is now emphasised both on the front page of the guideline as well as in the management algorithm. Lorazepam is suggested in a symptom-triggered fashion for patients with evidence of significant liver disease. Lorazepam or 50% of the standard diazepam dose is recommended for patients with other co-morbidities.

  3. Indication for Symptom-triggered Treatment: In the original form of the document a patient with withdrawal seizures and previous agitated withdrawal would automatically receive fixed-dose treatment. In the revised version withdrawal seizures or previous agitated withdrawal are part of a single indication. The threshold of initial GMAWS to consider fixed-dose treatment has been lowered to 4. Overall this should reduce the number of patients put on a fixed-dose treatment regime thereby optimising and shortening their treatment.

  4. Reducing Fixed-dose Treatment: Effective reduction of the fixed-dose treatment is necessary to avoid over-exposure to diazepam and to minimise the duration of hospital admission. Fixed-dose treatments should never be written up in anticipation but rather should be prescribed daily depending upon symptom break-through in the preceding 24 hours. The fixed-dose can be reduced if the GMAWS has been less than 4 for 24 hours.

  5. Senior Medical Review: There is a greater emphasis on the importance of senior medical review particularly if the patient requires more than 120mg of diazepam in 24-hours or is still requiring high dose treatment 96-hours since last alcohol ingestion.

  6. Prescription of Thiamine Supplements: It was noted that many patients were receiving the treatment dose of intravenous Pabrinex® even when this was not specifically indicated. The revised guideline again ensures patients with overt or suggested diagnosis of Wernicke’s encephalopathy are treated with high strength intravenous Pabrinex® as well as emphasising the importance of magnesium supplementation. In practice more patients will be deemed ‘at risk’ and the guidelines suggest intravenous Pabrinex® (just a single pair of vials) three times a day for either 24 or 48-hours depending upon risk factors identified by NICE (Clinical Guideline 100). We have also recommended that the optimal maintenance dose of oral thiamine be 50mg four times a day (higher doses not absorbed; more frequent dosing optimises availability).

It is hoped that these alterations will improve patient safety and management whilst not fundamentally altering the success of the GMAWS. The Alcohol Liaison Teams will be visiting all ward areas to increase awareness of these changes and can be contacted at anytime to discuss these changes. See below for details

Glasgow Acute Hospitals including Vale: Tel 0141 201 0204

Inverclyde Royal Hospital: Tel 01475 715 353

Royal Alexandra Hospital: 0141 314 4472

 

Published 07/09/2017