GROUP 1 Acebuque, Geramie Asuncion, Ruth Concepcion, Marissa De Guzman, Boris Jruing J.

Estorninos, Prima Donna Ibe, Richard Mendoza, Jay Ong, Robert Piguing, Ernesto Rodriguez, Isabelle Serafin, Jacob

CASE
Edwin, a 45 y/o male, sales executive and a known alcoholic, was brought to the rehabilitation center for treatment. On his 2nd day, patient developed disorientation, visual hallucinations and restlessness.

DEFINITION OF TERMS Alcoholism aka Alcohol dependence is characterized by compulsive and uncontrolled consumption of alcohol despite its negative effects on the drinker's health, relationships, and social standing. Disorientation a state of mental confusion characterized by inadequate or incorrect perceptions of place, time, or person. It may occur in organic mental disorders, in drug and alcohol intoxication, and, less commonly, after severe stress. Hallucinations - profound distortion in a person's perception of reality, typically accompanied by a powerful sense of reality. It may be a sensory experience in which a person can see, hear, smell, taste, or feel something that is not there. Visual Hallucination- hallucination involving the sense of sight Restlessness - characterized by or showing inability to remain at rest - never at rest; perpetually agitated or in motion: - without rest; without restfull sleep - unceasingly active; averse to quiet or inaction Wernicke-Korsakoff Syndrome - brain disorder due to thiamine deficiency. Causes: Wernicke's encephalopathy and Korsakoff syndrome are different conditions that are both due to brain damage caused by a lack of vitamin B1 (thiamine). A lack of vitamin B1 is common in people with alcoholism. It is also common in persons whose bodies do not absorb food properly (malabsorption), such as sometimes occurs after obesity surgery. Korsakoff syndrome, or Korsakoff psychosis, tends to develop as Wernicke's symptoms go away. Wernicke's encephalopathy causes brain damage in lower parts of the brain called the thalamus and hypothalamus. Korsakoff psychosis results from damage to areas of the brain involved with memory. TYPE OF ADVERSE DRUG REACTION According to the present ADR Classification Type E or the End of Use - Dose Dependent - Predictable ADR - Low Mortality but High Incidence - Metabolism and elimination affected by the presence of liver and kidney dysfunction.

PREDICTABILITY ADR of this type has a High/Positive Predictability. The higher the dose/the longer the use of the drug (in this case alcohol), the higher the predictability of occurrence of Adverse Reactions. two days after the sudden discontinuation of the drug (alcohol), ADR set in.

IMPLICATED DRUG Ethanol - also called ethyl alcohol, pure alcohol, grain alcohol, or drinking alcohol, is a volatile, flammable, colorless liquid. It is a powerful psychoactive drug and one of the oldest recreational drugs. It is best known as the type of alcohol found in alcoholic beverages and thermometers. In common usage, it is often referred to simply as alcohol or spirits.

DRUGS FOR TREATMENT Disulfiram inhibits aldehyde dehydrogenase, causes acetaldehyde accumulation. It may cause hepatotoxicity in itself or used in combination with other drugs. Naltrexone nonselective competitive antagonist of opioid receptors Acamprosate poorly understood NMDA antagonist and GABA-A agonist effects. May cause GIT irritation and rashes. Fomepizole inhibits alcohol dehydrogenase , prevents conversion of methanol and ethylene glycol to toxic metabolite. Benzodiazepine (e.g. diazepam) BDZ receptor agonist that facilitates GABA-mediated activation of GABA-A
Effect of ethanol GABA Acute ingestion stimulates GABA activity Withdrawal decreases GABA functioning Overactivity during alcohol ingestion and withdrawal Stimulation during withdrawal Increase in corticosteroid levels Repeated withdrawals increase neuronal responsivity Action of BZD Stimulation of GABA activity Increase of affinity of GABA to GABAA receptor Blockade of noradrenergic hyperactivity

Noradrenaline

Hypothalamicpituitaryadrenal axis Kindling effect

Decrease of withdrawal-induced corticosteroid increase

Blockade of withdrawal reactions and decreased probability of seizure activity Kindling is defined as 'the progressive increase in neuronal responsivity produced by spaced and repeated epileptogenic stimulation. (Ballenger and Post,1978)

TREATMENT PLAN Assess the Liver and Kidney function Upon Rehab: 1. Benzodiazepine Treatment of the alcohol-withdrawal syndrome is the first step towards the rehabilitation of alcohol dependent patients. The objectives of treatment should be the relief of suffering, as well as prevention and/or treatment of

complications such as seizures, or delirium tremens. Fulfilment of these objectives ensures a smoother transition into a long-term rehabilitation programme. The ideal drug for alcohol withdrawal should have a rapid onset and a long duration of action, a wide margin of safety, a metabolism not dependent on liver function, and absence of abuse potential (Nutt et al., 1989). Various BZDs offer many of these advantages. BZDs have been found effective in: (1) preventing agitation and alcoholwithdrawal seizures; (2) preventing delirium tremens; and (3) as cross tolerant agents with ethanol. BZDs, owing to their wide margin of safety and low potential to produce physical dependence and tolerance in short-course therapy, are therefore very effective in the treatment of alcohol-withdrawal syndrome. Their indication represents the drugs of choice (Ozdemir et al., 1993). Their widespread use has decreased the occurrence of lifethreatening consequences of alcohol withdrawal, such as delirium tremens (Fuller and Gordis, 1994). Following the use of chlordiazepoxide, many other BZDs have been used successfully. Diazepam, lorazepam, oxazepam, alprazolam, and halazepam have been shown to be safe and effective in the treatment of the alcohol-withdrawal syndrome (Pepers, 1996). 1. Thiamine to relieve the Alcohol withdrawal syndrome and WernickeKorsakoff Syndrome 2. Electrolyte Solutions if patient is dehydrated due to severe vomiting Upon Discharge: Disulfiram to prevent relapse of alcoholism

REFERENCES: Katzung, et al. Basic and Clinical Pharmacology.11th edition Lejoyeux M, et. al, Benzodiazepine Treatment for Alcohol Dependent Patients, Oxford Journals, USA. -http://en.wikipedia.org/wiki/Alcoholism -Mosby's Medical Dictionary, 8th edition. 2009, Elsevier http://www.medterms.com/script/main/art.asp?articlekey=24171 http://dictionary.reference.com/browse/restless http://www.nlm.nih.gov/medlineplus/ency/article/000771.htm