A medical resident wrote an order for “clonidine 0.1 mg PO every 6 hours PRN alcohol withdrawal.” Wow. The pharmacy resident and nurse had no idea how to clarify this order. To best educate the resident, I felt that it was best to research the topic and see what the medical resident had in mind.
After alcohol consumption, alcohol adheres to receptors in the brain. Alcohol blocks the receptors’ actions. Receptors have their own function. Initially, alcohol blocks glutamate, which makes you feel “free” and “uninhibited”. Feelings of inhibition can lead to inappropriate legal and moral choices. Alcohol worsens the situation by releasing dopamine, the hormone responsible for the “buzzed” feeling. At this point, the drinker will not care about their choices and consequences because they feel buzzed. With more alcohol consumed, receptors responsible for speech, walking, and motor coordination will be inhibited. Shortly, the drinker will become inebriated or drunk.
As time wears on and alcohol is cleared from the system, the receptors that were blocked by alcohol become hypersensitive. Consequently, people suffering from withdrawals are at risk for irritability, insomnia, hallucinations, fast heart rate, high blood pressure, and seizures. At the same time, receptors that were facilitated by alcohol become slower to turn back on and thus, tolerance to alcohol develops. As a result, chronic drinkers will have to consume more alcohol to achieve the initial effects of euphoria or “buzz”. This is called physiologic tolerance. The vicious cycle of alcoholism begins here.
When drinkers become hospital patients, they are usually in the acute phase of the alcohol withdrawal and suffering from severe symptoms such as tremors, agitation, delirium, tachycardia, hypertension, seizures, hallucinations, or even coma (after large doses of alcohol). At this time, there is no treatment for alcohol intoxication. Physicians are merely treating the symptoms of withdrawal. Ultimately, the best treatment for alcohol intoxication is abstinence, which should be managed on an outpatient basis.
Thiamine deficiency (secondary to malnutrition) and a severe form of thiamine deficiency called the Wernicke–Korsakoff syndrome. Patients can suffer from encephalopathy then followed by long-term psychosis.
In conclusion, the resident did know about the off-label use of clonidine for alcohol withdrawal. However, the dosing was incorrect and there was no concurrent use of a scheduled benzodiazepine. The patient did suffer from hypertension, which he was given clonidine from a previous PRN order for BP above 180/110. To prevent future medication errors, the resident was educated on the correct use of clonidine in this setting.
Dr. Karine Wong has a 10 year history of working in hospital management and 2 years as a hospital pharmacist and outpatient pharmacist. She recently published a children's book called Don't Sit on Her.
Comment on this article or post an article by joining the RxEconsult community.
Please Share on Your Social Networks