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alcoholism (includes binge drinking)

Classification: - classified as a mood disorder in DSM IV - binge drinking is defined as >= 5 drinks during a single occasion for men & >=4 drinks during a single occasion for women [22] Etiology: - risk factors a) bereavement b) other losses (diminished mobility, social network, income) c) previous history of substance abuse d) comorbid psychiatric disorders e) family history of alcohol problems f) comcommitant substance abuse (tobacco, psychoactive prescription drugs) g) genetic susceptibility to alcoholism (see genetics below) h) marriage to a person without alcohol use disorder is a negative risk factor [25] Epidemiology: 1) 10-20% of men & 3-10% of women develop pervasive & perisistent problems with alcohol 2) most alcoholics have a family & a job 3) 5% of alcoholics are homeless 4) 1% of pregnant women binge drink [13] 5) binge drinking highest among adolescents who drink [24] Genetics: - susceptibility to alcoholism associated with a) polymorphisms in: GABRA2, SLC6A4, DRD2, CHRM2, TAS2R16 - genetic variant in KLB (beta-klotho) appear to confer appetite for alchohol [29] (also see Comparative biology section below) Clinical manifestations: (evaluation) 1) CAGE questions 2) 2 question screen a) Have you ever had a drinking problem? b) When was your last drink? (+ response is within last 24 h) 3) single-question screening for alcohol abuse 4) others (see screening for alcohol abuse) 5) alcohol abuse a) failure to fulfill major role obligations b) use in hazardous situations c) legal problems d) social or interpersonal problems - poor academic performance e) headaches, nausea, memory impairment, elevated blood pressure [39] 6) alcohol dependence a) tolerance & withdrawal b) see addiction 7) repeated trauma Laboratory: 1) blood alcohol level, other laboratory findings non-specific 2) serum iron levels may be increased (but decrease 1-3 weeks after cessation of alcohol) 3) complete blood count (CBC) (MCV > 91 fL) 4) elevated serum transaminases, AST > ALT (> 2-fold) 5) serum gamma-glutamyl transferase (GGT) > 30 U/L 6) serum uric acid > 7.0 mg/dL 7) increased serum beta-2 transferrin 8) serum triglycerides > 180 mg/dL 9) abnormal serum electrolytes - diminished serum Na+, serum K+, serum Mg+2, serum Ca+2, serum phosphate 10) ethyl glucuronide in specimen - ethyl glucuronide in urine assesses alcohol consumption within the past 3 days - ethyl glucuronide in hair assesses alcohol consumption within the past 3 months 11) see ARUP consult [2] Radiology: - RUQ ultrasound - transient elastography to asssess cirrhosis - neuroimaging (CT or MRI) - widening of ventricles & sulci (cerebral atrophy) Differential diagnosis: - opiate withdrawal - aggression, hostility, agitation - yawning, lacrimation (specific to opiate withdrawal) [39] - cocaine abuse - mydriasis, diaphoresis, tachycardia, hypertension, hyperthermia - < 1% of illicit drug use in young adults [39] Complications: 1) dependence (alcohol withdrawal syndrome) - 90% of excessive drinkers are not alcohol-dependent [21] 2) depression 3) unintentional injury a) falls b) motor-vehicle accidents c) burns d) hypothermia 4) congenital defects (see congenital alcoholism) 5) sleep disorder - diminished REM sleep 6) nutritional disorders a) thiamine deficiency (Wernicke' syndrome) b) folate deficiency c) niacin deficiency (pellagra) 7) gastrointestinal a) fatty liver - hepatic cirrhosis - hepatic encephalopathy b) alcoholic hepatitis c) pancreatitis (acute & chronic) d) esophageal varices e) Mallory-Weiss tear f) impaired esophageal motility [6] g) lower esophageal sphincter impairment h) GERD, esophagitis [6] i) Barrett's esophagus [6] j) salivary injury, hyposalivation & parotid hypertrophy [6] k) glossitis & stomatitis [6] 8) hematopoietic a) macrocytic anemia b) thrombocytopenia 1] splenomegaly 2] direct suppression of platelet production c) sideroblastic changes in the bone marrow 9) endocrine a) hypoglycemia (ethanol inhibits gluconeogenesis) b) increased levels of serum cortisol c) diminished T3 & to a lesser extent T4 d) inhibition of vasopressin release [6] e) hypertension 10) central nervous system a) peripheral neuropathy (5-10%) b) Wernicke's syndrome c) cerebellar degeneration (1%) d) cerebral atrophy (may be reversible component) e) cognitive impairment (recent & remote memory) - heavy drinking in middle-age men accelerates cognitive decline [17] - may improve with sustained abstinence [7] f) dementia g) alcohol-induced psychosis (reversible) 1] occurs in the absence of withdrawal 2] auditory hallucinations 3] paranoid delusions 11) 10-fold increase in cancer a) head & neck b) esophagus, larynx, pharynx, tongue c) stomach (cardia) d) liver e) pancreas f) breast (possibly) g) 10% of total cancers in men & 3% in women are attributable to alcohol consumption [11] 12) cardiovascular a) dose-dependent increase in blood pressure* - binge drinking in men associated with elevated systolic BP [31] - greater frequency of binge drinking in men associated with a more unfavorable lipid profile [31] b) cardiomyopathy c) hemorrhagic stroke (> 3-8 drinks/day), especially within 24 hour of heavy drinking (GRS9) [7,27] d) 'holiday heart' (after binge drinking) 1] atrial & ventricular arrhythmias 2] paroxysmal tachycardia 13) sexual dysfunction a) increased sexual drive in men at levels < 100 mg/dL b) decrease in erectile capacity c) testicular atrophy d) amenorrhea, infertility & spontaneous abortions in women 14) musculoskeletal a) acute myopathy 1] painful swollen muscles 2] elevated serum creatine phosphokinase (CPK) 3] rarely myoglobinuria b) osteonecrosis of femoral head 15) immunologic - increase susceptibility to bacterial infections (pneumonia, tuberculosis) 16) coagulation a) fibrinolysis [6] b) impaired blood clotting [6] 17) skin a) rosacea b) facial edema c) rhinophyma d) psoriasis e) discoid eczema f) porphyria cutanea tarda 18) urologic: urinary incontinence 19) 10% of deaths in working age adults are related to excessive alcohol consumption [20] * low-doses of ethanol produce a transient (acute) drop in blood pressure Management: 1) detoxification (see alcohol withrawal syndrome) a) benzodiazepines b) clonidine* c) beta-blockers* 2) nutritional support a) thiamine 100 mg IM should be given to any alcoholic suspected of not eating in several days prior to any carbohydrate (i.e. glucose) administration b) oral B vitamins 1] thiamine 50-100 mg QD for at least 1 week 2] folate 1 mg QD 3) maintenance of abstinence a) behavioral therapy (psychosocial counseling) - a chronic care management program is no better than usual care in promoting abstinence in patients with alcohol or drug dependence [15] - a smartphone application may help reduce risky drinking among patients who have completed an inpatient alcohol rehabilitation program [18] b) naltrexone - effective [19] - only naltrexone has been studied in elderly [7] - 50 mg daily (of no benefit [5] without social support, counseling) - naltrexone 380 mg monthly [9] 1] may be started despite patient continuing to drink 2] effective in men & women [1] - also effective in reducing heavy drinking - contraindicated with hepatitis or cirrhosis [23] - avoid in patients on opiates [30] - combination of naltrexone plus sertraline suggested [10] c) acamprosate is as effective as naltrexone for maintenance of abstinence [19] - useful in patients with hepatitis or cirrhosis [23] - not effective in reducing heavy drinking - avoid in patients with severe renal impairment [30] d) ondansetron 4 ug/kg BID e) topiramate (Topamax) is effective [8,19] - start 25 mg PO QD - increase to 300 mg/day over 8 weeks f) nalmefene (Revex) is effective [19] g) disulfiram not effective; may be offered to patients [30] h) gabapentin - improves rates of abstinence [16] - not effective [19] i) smoking cessation [22] 4) psychotherapy - treatment of concurrent depression 5) screening & behavioral counseling after screening recommended by USPSTF [5] 6) hospital discharge may be an opportunity for initiation of treatment for alcohol use disorder [40] * do NOT prevent major withdrawal manifestations or seizures Comparative biology: - FGF21 inhibits alcohol drinking by acting on the brain - beta-klotho is a coreceptor for FGF21 & defects increase appetite of mice for alcohol [29]

Interactions

disease interactions

Related

alcohol withdrawal syndrome alcoholic beverage alcoholic hepatitis alcoholic liver disease (ALD) cirrhosis ethanol in serum/plasma/blood ethanol; ethyl alcohol ethyl glucuronide in specimen fetal alcohol syndrome hepatic encephalopathy screening for alcohol abuse Wernicke's syndrome (Wernicke's encephalopathy)

Specific

beer potomania congenital alcoholism (teratogenic effects of alcoholism)

General

alcohol abuse (includes alcohol use disorder, risky alcohol use) chronic disease

Database Correlations

OMIM 103780

References

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