Today’s USMLE® Step 1 question of the day features a young woman with anxiety and tremors after stopping alcohol use. What’s the best next step in management? Let’s find out!
A 21-year-old woman presents to the emergency department for moderate anxiety. She last consumed alcohol approximately 36 hours ago and has been binge drinking regularly at her university about four days a week for the past 10 months. She reports drinking 6–7 mixed drinks each time she drinks. She has never attempted to quit drinking, and she has had no prior withdrawal symptoms. She is not experiencing headaches, nausea, vomiting, hallucinations, or visual or tactile disturbances. The patient has no significant past medical history. She vapes tobacco products and uses marijuana occasionally. Temperature is 37°C (98.6°F), blood pressure is 148/80 mmHg, pulse is 98/min, respiratory rate is 16/min, oxygen saturation is 99% on room air. She has moderately sweaty palms. She has a moderate tremor with hands outstretched. A complete blood count, complete metabolic profile, alcohol level, and magnesium and phosphate levels are within normal limits. The patient is given IV fluids, thiamine, and glucose.
Which of the following is the best next step in management?
A. Administer intravenous phenobarbital and admit to the ICU
B. Discharge home with a prescription for oral gabapentin
C. Administer intravenous lorazepam and admit to the hospital
D. Discharge with a follow-up appointment with addiction medicine
E. Discharge with a prescription for oral buprenorphine
Scroll down for the correct answer!
The correct answer to today’s USMLE® Step 2 Question is…
B. Discharge home with a prescription for oral gabapentin
Correct: See Main Explanation.
Incorrect Answer Explanations
A. Administer intravenous phenobarbital and admit to the ICU
Incorrect: This patient does not demonstrate severe features of alcohol withdrawal, nor does she have significant risk factors for complications from alcohol withdrawal that would warrant administration of phenobarbital or ICU admission.
C. Administer intravenous lorazepam and admit to the hospital
Incorrect: This patient does not demonstrate severe features of alcohol withdrawal, nor does she have significant risk factors for complications that would warrant hospitalization and IV benzodiazepine therapy.
D. Discharge with a follow-up appointment with addiction medicine
Incorrect: Discharge without pharmacologic therapy for alcohol withdrawal would not be appropriate.
E. Discharge with a prescription for oral buprenorphine
Incorrect: Buprenorphine is indicated in the management of opiate use disorder, not alcohol withdrawal.
Main Explanation
This patient presents with mild alcohol withdrawal based on the Clinical Institute Withdrawal Assessment of Alcohol Scale Revised (CIWA-Ar) score, and she has no risk factors for severe withdrawal. Therefore, she can be discharged home with a prescription for oral anticonvulsants, such as gabapentin.
Patients presenting with alcohol withdrawal should have disease severity assessed with a tool like the CIWA-Ar scale. Additionally, the risk of severe withdrawal symptoms and complications from alcohol withdrawal should be determined. Patients with minimal to mild symptoms and a low risk for complications of severe withdrawal can be discharged home on oral medications. For mild withdrawal, anticonvulsants (e.g. gabapentin, carbamazepine) are preferred. For moderate withdrawal with low risk of complications, an oral benzodiazepine can be prescribed. Patients with moderate or severe withdrawal features and significant risk factors for complications should be admitted to the hospital for close monitoring. Inpatients should receive intravenous benzodiazepine therapy. Some severe cases may require ICU admission and phenobarbital. Additionally, thiamine should be administered to prevent or treat Wernicke encephalopathy.
Major Takeaway
Outpatient management of mild alcohol withdrawal should include pharmacotherapy with anticonvulsants (e.g. carbamazepine, gabapentin) to prevent progression of symptoms.
Want to learn more about this topic?
Watch the Osmosis video: Alcohol withdrawal: Clinical sciences
References
- Wong, J., Saver, B. G., Scanlan, J., Gianutsos, L. P., Bhakta, Y., Walsh, J. J., Plawman, A. R., Sapienza, D., & Rudolf, V. (2020). The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management.JournalofAddictionMedicine,14(3S),1–72. https://doi.org/10.1097/adm.0000000000000668
- Mayo-Smith MF, Beecher LH, Fischer TL, et al. Management of Alcohol Withdrawal Delirium: An Evidence-BasedPracticeGuideline.ArchInternMed.2004;164(13):1405–1412. doi:10.1001/archinte.164.13.1405
- Bayard M, McIntyre J, Hill KR, Woodside J Jr. Alcohol withdrawal syndrome. Am Fam Physician. 2004 Mar 15;69(6):1443-50. PMID: 15053409.
- Alcohol Use Disorders – Goldman-Cecil Medicine – ClinicalKey Student
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