Question

Medications for Substance Use Disorders: Managing Alcohol Withdrawal (RN QSEN - Safety , Active Learning Template - Medication, RM MH RN 10.0 Chp 26)

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ACTVE LEARNING TEMPAMedication STUDENT NAME MEDICATION CATEGORY CLASS REVMEW MODULE CHAPTER PURPOSE OF ME DICATION Expected Pharmacological Action Therapeutic Use Medication Administration Complications Contraindications/Precautions Nursing Interventions Interactions Client Education Evaluation of Medication Effectiveness

Answer 1

Student name: Ms X

Medication: Antabuse (disulfiram)

Category class: aldehyde dehydrogenase inhibitor /Antialcoholic drug, Enzyme inhibitor

Expected Pharmacologic action

Disulfiram irreversibly inhibits aldehyde dehydrogenase, which prevents the oxidation of alcohol after the acetaldehyde stage. It works by blocking the processing of alcohol in the body It interacts with ingested alcohol to produce acetaldehyde levels five to ten times higher than are produced by normal alcohol metabolism.

Therapeutic use

Adjunct in the management of chronic alcoholism

Complications

CNS: drowsiness, headache, fatigue, delirium, depression, neuritis, peripheral neuritis, polyneuritis, restlessness, psychotic reactions. EENT: optic neuritis. GI: metallic or garlic aftertaste. GU: Impotence. Hepatic: hepatotoxicity, cholestatic or fulminant hepatitis. Metabolic: elevated serum cholesterol levels. Skin: acneiform or allergic dermatitis, occasional eruptions. Other: disulfiram reaction (precipitated by alcohol use), which may include flushing, throbbing headache, dyspnea, nausea, copious vomiting, diaphoresis, thirst, chest pain, palpitations, hyperventilation, hypotension, syncope, anxiety, weakness, blurred vision, confusion, arthropathy. In severe reactions: respiratory depression, CV collapse, arrhythmias, MI, acute heart failure, seizures, unconsciousness, or death.

Medication Administration

Adults: Give a maximum dose of 500 mg P.O. as a single dose in the morning for 1 to 2 weeks. Can be taken in the evening if drowsiness occurs. Maintenance dosage is 125 to 500 mg daily (average dose of 250 mg) until permanent self-control is established. Treatment may continue for months or years.

Contraindications/Precautions

Contraindicated in patients intoxicated by alcohol and within 12 hours of alcohol ingestion; in those with psychoses, myocardial disease, coronary occlusion, or hypersensitivity to disulfiram or to other thiuram derivatives used in pesticides and rubber vulcanization; and in patients receiving metronidazole, paraldehyde, alcohol, or alcohol-containing preparations. Use with extreme caution in patients with diabetes mellitus, hypothyroidism, seizure disorder, cerebral damage, or nephritis or hepatic cirrhosis or insufficiency and with concurrent phenytoin therapy. Don’t administer the drug during pregnancy.

Interactions

Drug-drug. Bacampicillin: May precipitate disulfiram reaction. Don’t use together. Barbiturates, chlordiazepoxide, CNS depressants, coumarin anticoagulants, diazepam, midazolam, paraldehyde, phenytoin: Increases blood levels of these drugs. Use together cautiously. Hydantoins: May increase hydantoin levels. Monitor serum levels and patient for signs of toxicity. Isoniazid: Increases risk of ataxia, unsteady gait, or marked behavioural changes. Don’t use together. Metronidazole: Increases risk of psychosis or confusion. Avoid use together. Tricyclic antidepressants, especially amitriptyline: May cause transient delirium. Monitor patient closely. Warfarin: May increase the anticoagulant effects. Monitor PT and INR, and adjust the dose as needed. Drug-herb. Passionflower, pill-bearing spurge, pokeweed, squaw vine, squill, sundew, sweet flag, tormentil, valerian, yarrow: Causes disulfiram reaction if the herbal form contains alcohol. Discourage use together. Drug-food. Caffeine: May exaggerate or prolong effects of caffeine. Discourage use together. Drug-lifestyle. Alcohol use (all sources, including cough syrups, liniments, shaving lotions, back-rub preparations): May precipitate disulfiram reaction. Alcohol reaction may occur as long as 2 weeks after single disulfiram dose; the longer the patient remains on the drug, the more sensitive he becomes to alcohol. Advise the patient to be alert for and avoid the use of these products. Marijuana use: Causes synergistic CNS stimulation. Advise patient of this possible interaction.

Nursing Interventions

Assessment History: Allergy to disulfiram or other thiuram derivatives; severe myocardial disease or coronary occlusion; psychoses; current or recent treatment with metronidazole, paraldehyde, alcohol, alcohol-containing preparations (eg, cough syrups, tonics); diabetes mellitus, hypothyroidism, epilepsy, cerebral damage, chronic and acute nephritis, hepatic cirrhosis or impairment; pregnancy Physical: Skin colour, lesions; thyroid palpation; orientation, affect, reflexes; P, auscultation, BP; R, adventitious sounds; liver evaluation; LFTs, renal function tests, CBC, SMA-12 Interventions Do not administer until the patient has abstained from alcohol for at least 12 hr. Administer orally; tablets may be crushed and mixed with liquid beverages. Monitor liver function tests before, in 10–14 days, and every 6 mo during therapy to evaluate for hepatic impairment. Monitor CBC, SMA-12 before and every 6 months during therapy. Inform patient of the seriousness of disulfiram-alcohol reaction and the potential consequences of alcohol use. Disulfiram should not be taken for at least 12 hr after alcohol ingestion and a reaction may occur up to 2 wk after disulfiram therapy is stopped; all forms of alcohol must be avoided. Arrange for treatment with antihistamines if skin reaction occurs. WARNING: Institute supportive measures if a disulfiram-alcohol reaction occurs; oxygen, carbon dioxide combination, massive doses of vitamin C IV, ephedrine have been used.

Client Education

• Explain that, although disulfiram can help discourage the use of alcohol, it isn’t a cure for alcoholism. • Warn patient to avoid all sources of alcohol: sauces or soups made with sherry or other wines or alcohol (even "cooking alcohol"), some herbal preparations, and cough syrups. External applications of after-shave lotion, liniments, or other topical preparations may cause disulfiram reaction (because of the products’ alcohol content). • Warn patient that drug may cause drowsiness. • Instruct patient to carry an identification card stating that disulfiram is being used and including the telephone number of prescriber or clinic to contact if a reaction occurs.

Evaluation of medication effectiveness

Patients show motivation for treatment and committed to total abstinence Patients capable of understanding the consequences of drinking alcohol while taking disulfiram Patients abstinent from alcohol Patients who maintain abstinence during treatment