Diagnostik und Therapie des Alkoholentzugssyndroms: Fokus auf Delirium tremens und Entzugskrampfanfall

Zusammenfassung

Einleitung Die schwerwiegendsten Komplikationen des Alkoholentzugssyndroms sind der Entzugskrampfanfall und das Delirium tremens. Die Übersichtsarbeit stellt das notwendige diagnostische, therapeutische und prophylaktische Vorgehen sowie nichtpharmakologische Therapiemaßnahmen beim Delirium tremens und eine mögliche Integration von Videoaufnahmen des Delirium tremens im Rahmen der Motivationsbehandlung dar. Methodik Systematische Literaturrecherche mithilfe der Datenbank Pubmed. Ergebnisse und Diskussion Beim Auftreten eines Entzugskrampfanfalls bzw. eines Delirium tremens muss zwischen einer Basisdiagnostik und einer weiterführenden, zustandsabhängigen Diagnostik (Bildgebung, Liquorpunktion) unterschieden werden. In der Behandlung und Prophylaxe des Entzugssyndroms haben Sedativa einen hohen Stellenwert. Eine dauerhafte antikonvulsive Medikation nach einem Entzugskrampfanfall ist äußerst kritisch zu prüfen.

Abstract

Introduction Delirium tremens and withdrawal seizures are serious complications of an alcohol withdrawal syndrome. This review presents the diagnostic procedures required in case of the occurrence of a withdrawal seizure and delirium tremens as well as possible treatment options including prophylactic medication regimen for alcohol withdrawal syndrome. Furthermore non-pharmacological procedures accompanying delirium tremens and a potential integration of viewing videotapes of delirium tremens in the course of alcohol-specific therapy are discussed. Methods A systematic literature research using Pubmed has been carried out to find recent studies and review articles dealing with alcohol withdrawal syndrome. Results and Discussion Regarding the diagnostic algorithm in case of the occurrence of a withdrawal seizure or a delirium tremens basic diagnostic procedures and special diagnostics including neuro-imaging or cerebrospinal fluid puncture depending on patients' clinical condition have to be considered. Sedatives are important in treatment of alcohol withdrawal seizures and delirium tremens as well as in the prophylaxis of alcohol withdrawal syndrome. A long-lasting prescription of anticonvulsant medication in patients suffering from withdrawal seizure should be considered critically and can be carried out only under certain conditions.

Schlüsselwörter

Alkoholentzug - Delirium tremens - Krampfanfall - Therapie - Diagnostik

Keywords

alcohol withdrawal - delirium tremens - seizure - therapy - diagnostics

Literatur

• 1 Küfner H, Kraus L. Epidemiologische und ökonomische Aspekte des Alkoholismus.  Dtsch Arztebl. 2002;  99 936-945
• 2 Bergmann E, Horch K. Ökonomische Bewertung von gesundheitlichen Folgen des Alkoholismus.  Sucht aktuell. 2000;  2 14-18
• 3 Bundesministerium für Gesundheit .Drogen- und Suchtbericht. http://www.bmgs.bund.de 2008
• 4 Wetterling T. Delir – der Stand der Forschung.  Fortschr Neurol Psychiatr. 1994;  62 280-289
• 5 Erwin W E, Williams D B, Speir W A. Delirium tremens.  South Med J. 1998;  91 425-432
• 6 Zilker T. Alkoholentzugssyndrom und Delirium tremens.  MMW Fortschr Med. 1999;  141 26-30
• 7 Ferguson J A, Suelzer C J, Eckert G J. et al . Risk factors for delirium tremens development.  J Gen Intern Med. 1996;  11 410-414
• 8 Lutz U C, Batra A. Das Alkoholentzugssyndrom: Delirium tremens und Krampfanfall – eine Übersicht über die Ätiopathogenese.  SUCHT. 2010 (in Druck); 
• 9 Victor M, Brausch C. The role of abstinence in the genesis of alcoholic epilepsy.  Epilepsia. 1967;  8 1-20
• 10 Hillbom M, Pieninkeroinen I, Leone M. Seizures in alcohol-dependent patients: epidemiology, pathophysiology and management.  CNS Drugs. 2003;  17 1013-1030
• 11 Hillbom M E. Occurrence of cerebral seizures provoked by alcohol abuse.  Epilepsia. 1980;  21 459-466
• 12 Krumholz A, Grufferman S, Orr S T. et al . Seizures and seizure care in an emergency department.  Epilepsia. 1989;  30 175-181
• 13 Forsgren L. Prevalence of epilepsy in adults in northern Sweden.  Epilepsia. 1992;  33 450-458
• 14 Granieri E, Rosati G, Tola R. et al . A descriptive study of epilepsy in the district of Copparo, Italy, 1964–1978.  Epilepsia. 1983;  24 502-514
• 15 Chan A W. Alcoholism and epilepsy.  Epilepsia. 1985;  26 323-333
• 16 Foy A, Kay J. The incidence of alcohol-related problems and the risk of alcohol withdrawal in a general hospital population.  Drug Alcohol Rev. 1995;  14 49-54
• 17 Kosten T R, O'Connor P G. Management of drug and alcohol withdrawal.  N Engl J Med. 2003;  348 1786-1795
• 18 Sullivan J T, 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 1353-1357
• 19 Wetterling T, Kanitz R D, Besters B. et al . A new rating scale for the assessment of the alcohol-withdrawal syndrome (AWS scale).  Alcohol Alcohol. 1997;  32 753-760
• 20 Soyka M, Küfner H, Feuerlein W. Alkoholismus – Missbrauch und Abhängigkeit: Entstehung – Folgen – Therapie. Stuttgart; Thieme 2007
• 21 Bayard M, McIntyre J, Hill K R. et al . Alcohol withdrawal syndrome.  Am Fam Physician. 2004;  69 1443-1450
• 22 Soyka M, Lutz W, Kauert G. et al . Epileptische Anfälle im Alkoholentzug.  Psycho. 1989;  15 244-255
• 23 McKeon A, Frye M A, Delanty N. The alcohol withdrawal syndrome.  J Neurol Neurosurg Psychiatry. 2008;  79 854-862
• 24 Tartara A, Manni R, Mazzella G. Epileptic seizures and alcoholism. Clinical and pathogenetic aspects.  Acta Neurol Belg. 1983;  83 88-94
• 25 Leitlinie für Diagnostik und Therapie in der Neurologie; 3. überarbeitete Auflage. Stuttgart; Thieme 2005
• 26 Soyka M, Schmidt F, Schmidt P. Efficacy and safety of outpatient alcohol detoxification with a combination of tiapride / carbamazepine: additional evidence.  Pharmacopsychiatry. 2006;  39 30-34
• 27 Mundle G, Banger M, Mugele F. et al . Alkoholbezogene Störungen, Akutbehandlung. In: Schmidt LG, Gastpar M, Falkai P, Gaebel W Evidenzbasierte Suchtmedizin. Köln; Deutscher Ärzte-Verlag 2006: 25-52
• 28 Cook C C, Thomson A D. B-complex vitamins in the prophylaxis and treatment of Wernicke-Korsakoff syndrome.  Br J Hosp Med. 1997;  57 461-465
• 29 Cross A J, Stirling J M, Robinson T N. et al . The modulation by chlormethiazole of the GABAA-receptor complex in rat brain.  Br J Pharmacol. 1989;  98 284-290
• 30 Pentikainen P J, Neuvonen P J, Tarpila S. et al . Effect of cirrhosis of the liver on the pharmacokinetics of chlormethiazole.  Br Med J. 1978;  23 861-863
• 31 Morgan M Y. The management of alcohol withdrawal using chlormethiazole.  Alcohol Alcohol. 1995;  30 771-774
• 32 Hillemacher T, Weinland C, Heberlein A. et al . Treatment with clomethiazole is associated with lower rates of premature discharge during alcohol withdrawal.  Pharmacopsychiatry. 2008;  41 134-137
• 33 Holbrook A M, Crowther R, Lotter A. et al . Meta-analysis of benzodiazepine use in the treatment of acute alcohol withdrawal.  Can Med Assoc J. 1999;  160 649-655
• 34 Amato L, Minozzi S, Vecchi S. et al . Benzodiazepines for alcohol withdrawal.  Cochrane Database Syst Rev. 2010;  3 , CD005063
• 35 Ntais C, Pakos E, Kyzas P. et al . Benzodiazepines for alcohol withdrawal.  Cochrane Database Syst Rev. 2005;  20 , CD005063
• 36 Bird R D, Makela E H. Alcohol withdrawal: what is the benzodiazepine of choice?.  Ann Pharmacother. 1994;  28 67-71
• 37 Solomon J, Rouck L A, Koepke H H. Double-blind comparison of lorazepam and chlordiazepoxide in the treatment of the acute alcohol abstinence syndrome.  Clin Ther. 1983;  6 52-58
• 38 Ritson B, Chick J. Comparison of two benzodiazepines in the treatment of alcohol withdrawal: effects on symptoms and cognitive recovery.  Drug Alcohol Depend. 1986;  18 329-334
• 39 Holzbach R. Benzodiazepinabhängigkeit.  Abhängigkeiten. 2000;  2 5-16
• 40 Holzbach R. Weiter verschreiben oder stoppen? Die Langzeiteinnahme von Benzodiazepinen.  Der Neurologe, Psychiater. 2005;  10 45-47
• 41 Saitz R, Mayo-Smith M F, Roberts M S. et al . Individualized treatment for alcohol withdrawal. A randomized double-blind controlled trial.  JAMA. 1994;  272 519-523
• 42 Hodges B, Mazur J E. Intravenous ethanol for the treatment of alcohol withdrawal syndrome in critically ill patients.  Pharmacotherapy. 2004;  24 1578-1585
• 43 Peters D H, Faulds D. Tiapride. A review of its pharmacology and therapeutic potential in the management of alcohol dependence syndrome.  Drugs. 1994;  47 1010-1032
• 44 Lucht M, Kuehn K U, Armbruster J. et al . Alcohol withdrawal treatment in intoxicated vs non-intoxicated patients: a controlled open-label study with tiapride / carbamazepine, clomethiazole and diazepam.  Alcohol Alcohol. 2003;  38 168-175
• 45 Kraus M L, Gottlieb L D, Horwitz R I. et al . Randomized clinical trial of atenolol in patients with alcohol withdrawal.  N Engl J Med. 1985;  313 905-909
• 46 Sellers E M, Zilm D H, Degani N C. Comparative efficacy of propranolol and chlordiazepoxide in alcohol withdrawal.  J Stud Alcohol. 1977;  38 2096-2108
• 47 Björkqvist S E. Clonidine in alcohol withdrawal.  Acta psychiatr Scand. 1975;  52 256-263
• 48 Wilkins A J, Jenkins W J, Steiner J A. Efficacy of clonidine in treatment of alcohol withdrawal state.  Psychopharmacology (Berl). 1983;  81 78-80
• 49 Björkqvist S E, Isohanni M, Mäkelä R. et al . Ambulant treatment of alcohol withdrawal symptoms with carbamazepine: a formal multicentre doubl-blind comparison with placebo.  Acta psychiatr Scand. 1976;  53 333-342
• 50 Bonnet U, Schäfer M, Richter C. et al . Antikonvulsiva in der Behandlung der Alkoholabhängigkeit.  Fortschr Neurol Psychiatr. 2009;  77 192-202
• 51 Malcolm R, Myrick H, Roberts J. et al . The effects of carbamazepine and lorazepam on single versus multiple previous alcohol withdrawals in an outpatient randomized trial.  J Gen Intern Med. 2002;  17 349-355
• 52 Schik G, Wedegaertner F R, Liersch J. et al . Oxcarbazepine versus carbamazepine in the treatment of alcohol withdrawal.  Addict Biol. 2005;  10 283-288
• 53 Koethe D, Juelicher A, Nolden B M. et al . Oxcarbazepine – efficacy and tolerability during treatment of alcohol withdrawal: a double-blind, randomized, placebo-controlled multicenter pilot study.  Alcohol Clin Exp Res. 2007;  31 1188-1194
• 54 Minozzi S, Amato L, Vecchi S. et al . Anticonvulsants for alcohol withdrawal.  Cochrane Database Syst Rev. 2010;  3 , CD005064
• 55 Krupitsky E M, Rudenko A A, Burakov A M. et al . Antiglutamatergic strategies for ethanol detoxification: comparison with placebo and diazepam.  Alcohol Clin Exp Res. 2007;  31 604-611
• 56 Addolorato G, Leggio L, Abenavoli L. et al . Baclofen in the treatment of alcohol withdrawal syndrome: a comparative study vs diazepam.  Am J Med. 2006;  119 e13-18
• 57 Stallings W, Schrader S. Baclofen as prophylaxis and treatment for alcohol withdrawal: a retrospective chart review.  J Okla State Med Assoc. 2007;  100 354-360
• 58 O'Connor A B, Lang V J. Baclofen not comparable to diazepam for alcohol withdrawal.  Am J Med. 2007;  120 e5
• 59 Saitz R. Baclofen for alcohol withdrawal: not comparable to the gold standard (benzodiazepines).  Am J Med. 2007;  120 e9
• 60 Leone M A, Vigna-Taglianti F, Avanzi G. et al . Gamma-hydroxybutyrate (GHB) for treatment of alcohol withdrawal and prevention of relapses.  Cochrane Database Syst Rev. 2010;  2 , CD006266
• 61 Meagher D J. Delirium: optimising management.  Br Med J. 2001;  322 144-149
• 62 Mayo-Smith M F, Beecher L H, Fischer T L. et al., Working Group on the Management of Alcohol Withdrawal Delirium, Practice Guidelines Committee, American Society of Addiction Medicine . Management of alcohol withdrawal delirium. An evidence-based practice guideline.  Arch Intern Med. 2004;  164 1405-1412
• 63 Mayo-Smith M F. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal . Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline.   JAMA. 1997;  278 144-151
• 64 Caspari D, Wappler M, Bellaire W. Treatment of delirium tremens – a comparison between clomethiazole and clorazepate with reference to effectiveness and rate of side effects.  Psychiat Prax. 1992;  19 23-27
• 65 Athen D. Comparative investigation of chlormethiazole and neuroleptic agents in the treatment of alcoholic delirium.  Acta psychiatr Scand Suppl. 1986;  329 167-170
• 66 Feuerlein W, Reiser E. Parameters affecting the course and results of delirium tremens treatment.  Acta psychiatr Scand Suppl. 1986;  329 120-123
• 67 D'Onofrio G, Rathlev N K, Ulrich A S. et al . Lorazepam for the prevention of recurrent seizures related to alcohol.  N Engl J Med. 1999;  340 915-919
• 68 Chance J F. Emergency department treatment of alcohol withdrawal seizures with phenytoin.  Ann Emerg Med. 1991;  20 520-522
• 69 Rathlev N K, D'Onofrio G, Fish S S. et al . The lack of efficacy of phenytoin in the prevention of recurrent alcohol-related seizures.  Ann Emerg Med. 1994;  23 513-518
• 70 Alldredge B K, Lowenstein D H. Status epilepticus related to alcohol abuse.  Epilepsia. 1993;  34 1033-1037
• 71 Hauser W A, Ng S K, Brust J C. Alcohol, seizures, and epilepsy.  Epilepsia. 1988;  29 (Suppl. 2) S66-78
• 72 MacDonald B K, Johnson A L, Goodridge D M. et al . Factors predicting prognosis of epilepsy after presentation with seizures.  Ann Neurol. 2000;  48 833-841
• 73 Rathlev N K, Ulrich A, Shieh T C. et al . Etiology and weekly occurrence of alcohol-related seizures.  Acad Emerg Med. 2002;  9 824-828
• 74 Berg A T, Shinnar S. The risk of seizure recurrence following a first unprovoked seizure: a quantitative review.  Neurology. 1991;  41 965-972
• 75 Hillbom M E, Hjelm-Jäger M. Should alcohol withdrawal seizures be treated with anti-epileptic drugs?.  Acta Neurol Scand. 1984;  69 39-42
• 76 Mihai A, Damsa C, Allen M. et al . Viewing videotape of themselves while experiencing delirium tremens could reduce the relapse rate in alcohol-dependent patients.  Addiction. 2007;  102 226-231
• 77 Bühringer G, Hoch E. Viewing videotapes of one's own delirium tremens: renaissance of alcohol dependence as ,disease of the will‘?.  Addiction. 2007;  102 183-184
• 78 Polcin D L. Rethinking Confrontation in Alcohol and Drug Treatment: Consideration of the Clinical Context.  Subst Use Misuse. 2003;  38 165-184
• 79 Miller W R, Benefield R G, Tonigan J S. Enhancing motivation for change in problem drinking: a controlled comparison of two therapist styles.  J Consult Clin Psychol. 1993;  61 178-183
• 80 Miller W R. Rediscovering fire: small interventions, large effects.  Psychol Addict Behav. 2000;  14 6-18