JISC UPDATE MARCH 2012
Update on case of NMDA encephalopathy:
This patient was treated with antibody therapy and quetiapine, and
she gradually improved. She was moved into a brain injury
rehabilitation centre and was shortly to be discharged apparently well.
She has not yet had formal neuropsychological testing and it is
suspected that they may be subtle deficits; but all in all she made a
remarkable recovery.
Buproprion
Have clinicians used bupropion in Chronic Fatigue Syndrome with or
without depression?
In the UK it is not licensed for either but this clinician had a patient
who was interested in trying bupropion.
An American respondent said it was used frequently as monotherapy
for depression there; especially in patients concerned about weight
gain and sexual dysfunction. It does not seem effective in agitated
depression, or in depression accompanied by significant anxiety. He
would be more optimistic if the patient's diagnosis was depression
and CFS.
He uses 300-450 mg per day, but occasionally patient gets a good
response at just 150-200mg is effective. It is worth knowing that the
seizure risk that every textbook warns about has been exaggerated. It
has been forgotten that when bupropion (immediate release) was first
introduced in the US, it was at an approved dose range of up to 750
mg.
Alcohol – an extensive discussion
A Scottish colleague is reviewing the advice her service gives on the
management of DTs and alcohol withdrawal in the general hospital.
She wondered:
1) Do liaison services give advice on prescribing? If so, who gives this
advice?
2) Do liaison services have any protocols?
3) Do liaison services use symptom triggered or fixed regimes?
4) Do liaison services use diazepam, chlordiazepoxide, or something
else?
A respondent said that NICE recommends that triggered regimes are
suited to teams that are highly trained in management of withdrawal.
There is a lot of interest in RAID and the benefits of a dedicated
Liaison Alcohol and Substance Consultant to support such
implementation.
Another very helpful response stated that they ‘get stuck in with
alcohol withdrawal’; the rationale being that if you don’t then patients
are referred later on with poorly managed detoxes and symptoms that
the medics/surgeons interpret as "psychiatric".
This psychiatrist thinks this is an area where liaison can really help
patients and reduce readmissions, and he chairs the hospital alcohol
strategy group. In this hospital:
1) The liaison team and the alcohol link worker (employed by the local
alcohol agency, but working at the acute trust) give advice readily.
2) There is an explicit protocol drawn up by gastroenterology,
pharmacy, liaison, nursing and local alcohol teams.
3) It is symptom triggered for 24 hours. Then the total dose for the
first 24 hours is converted in to a fixed reducing regime with no prn
for the next three to four days.
4) Chlordiazepoxide is used unless there is "liver failure" (high INR or
Bilirubin) in which case Oxazepam is used.
Ward nurses do 2 hourly CIWA scores for the first 24 hours and give a
dose of chlordiazepoxide according to score (like an insulin sliding
scale). Much effort was put in to training. Their acute medical unit (60
beds) and three other wards of 30 beds can all do it without much
difficulty.
But things still go wrong – e.g. problems getting A & E to start detoxes
in timely way, patients drinking the hand gel etc.
Overall though the detox situation is a lot better than it was.
And they have noted some advantages that weren’t anticipated:
There are fewer admissions for detox only - now rare. It's a lot easier
not to admit people who don't have a co-morbid medical problem
when the alcohol pathways are more explicit.
Also, sometimes you will be the only psychiatrist to have assessed a
patient when remotely sober - I probably see about 1 in 10 of our
alcohol dependent patients each time round. A post-detox assessment
can make a big difference to how generic mental health services
respond to patients.
Another respondent answered:
1) Locally this is managed by addictions liaison nurses supported by a
consultant addiction psychiatrist 9-5, with the general liaison service
only getting involved out of hours or in exceptional circumstances.
There is considerable variation between sites: 24h cover by senior
nurses with >10yr experience on detox wards on two sites, vs a
community alcohol worker visiting the MAU ward round on another.
Much advice is given by both nurses and doctors.
2) They have a two-page information sheet, plus a copy of the CIWA-Ar
and an observation chart for serial CIWA-Ar scoring.
3) Practice varies. MAU wards may use symptom-triggered regimes,
with fixed regimes (+ prn doses for 24-48h) on other wards - on the
basis that general hospital nurses don't necessarily have the expertise
to assess withdrawal and administer medication (i.e. training required
for symptom-triggered regimes, to avoid people attempting to treat
withdrawal symptoms with antiemetics, analgesics and antipsychotics)
4) Chlordiazepoxide is used unless there is hepatic impairment, in
which case oxazepam is used. The criterion on the detox unit is
oxazepam if GGT>1000. On our detox ward we also use diazepam
"front-loading" schedules - i.e. up to 100mg of diazepam in the first
24h in increments of 5-20mg, and no more thereafter, relying on the
long half-life to cover withdrawal symptoms. He would be
uncomfortable prescribing a reducing schedule of diazepam over
several days in view of its likely accumulation.
Also: Locally it is crucial to keep impressing on successive waves of
junior doctors how important it is to give parenteral thiamine. They
have had patients admitted/transferred with frank Wernicke's who
have had "door-to-needle" times in excess of 12h in the recent past.
He also asked:
5) Is anyone using a diazepam "front loading" detox schedule in a
general hospital (see 4 below)?
An Irish colleague answered: ‘Yes. Diazepam 20mg every 90 minutes if
CIWA-Ar >10 but only in the CDU of the ED, not in the main
department or inpatient wards as less predictable staffing
environment. When CIWA<10 x 3 or if >24 hours then stop. This can
reduce LOS and cumulative BDZ dose. Reference: Symptom-triggered
benzodiazepine therapy for alcohol withdrawal syndrome in the
emergency department: a comparison with the standard fixed dose
benzodiazepine regimen. Cassidy et al, EMJ 2011
A further response helpfully attached their policy on the management
of patients in alcohol withdrawal. The ED and ward nursing staff are
very competent at monitoring patients at risk of withdrawals. They use
Diazepam 20 mg as standard treatment, but substitute with Oxazepam
if the LFTs indicate poor liver function. The journal reference at the
end of the policy (Foy et al) was written by D&A clinicians at their site.
Alcohol
Withdrawal.PDF
Jackie Gordon
Worthing