Daily Archives: January 14, 2025

Review: Management of Alcohol Withdrawal Syndromes in General Hospital Settings

14 Jan, 2025 | 12:33h | UTC

Introduction:
This summary provides an overview of a state-of-the-art review on identifying, assessing, and treating alcohol withdrawal syndromes among patients in general hospital settings. The rising prevalence of heavy alcohol use—and the sharp increase in hospital admissions for alcohol withdrawal during and after the COVID-19 pandemic—underscores the need for clear, evidence-based guidance. This review addresses the epidemiology, pathophysiology, clinical features, screening tools, and pharmacologic options for managing alcohol withdrawal. It also highlights nutritional considerations and the importance of preventing relapse to reduce readmissions and improve patient outcomes.

Key Recommendations:

1. Screening and Risk Stratification:
   • Use brief, validated questionnaires (eg, Single Alcohol Screening Question or AUDIT-C) to identify at-risk alcohol use.
   • Employ biomarker tests (eg, blood alcohol level, PEth, EtG) when possible to confirm recent intake and evaluate heavy use.
   • Consider standardized risk scales (eg, PAWSS) to identify patients likely to develop severe withdrawal and guide treatment intensity.
2. Symptom Severity Assessment:
   • Select a validated tool to monitor withdrawal progress (eg, CIWA-Ar).
   • For patients with altered mental status or unreliable self-report, consider alternative scales (eg, BAWS or GMAWS) that rely more on objective signs.
3. Benzodiazepine Therapy:
   • Continue to regard benzodiazepines (particularly long-acting agents like diazepam or chlordiazepoxide) as first-line therapy for prevention of seizures and delirium.
   • In patients with liver dysfunction or advanced age, short-acting options (eg, lorazepam, oxazepam) may be safer.
   • Symptom-triggered regimens can reduce total benzodiazepine exposure in lower-risk patients but require trained staff and structured protocols.
   • Fixed-schedule or loading-dose regimens may be warranted in severe withdrawal cases or when symptom-triggered approaches prove insufficient.
4. Alternative and Adjunctive Pharmacotherapies:
   • Phenobarbital: Offers GABA-enhancing and anti-glutamatergic effects, useful in severe or benzodiazepine-resistant withdrawal; consider ICU-level monitoring for high-risk patients.
   • Alpha-2 Adrenergic Agonists (clonidine, dexmedetomidine): Adjunctive benefit for persistent autonomic instability (tachycardia, hypertension), but these agents do not prevent seizures or delirium if used alone.
   • Antiseizure Medications (eg, carbamazepine, gabapentin, valproate): May aid in mild cases or adjunctively, but current evidence does not support them as stand-alone agents in severe withdrawal.
5. Nutritional Repletion and Thiamine Replacement:
   • Aggressively treat thiamine deficiency (eg, IV thiamine 200–500 mg daily) to prevent or halt Wernicke-Korsakoff syndrome.
   • Correct additional deficits (eg, folate, magnesium) for better overall recovery.
6. Relapse Prevention and Post-Acute Care:
   • Initiate FDA-approved medications (eg, naltrexone or acamprosate) during admission to reduce relapse risk after discharge.
   • Provide psychosocial support and referral to continuing addiction services (eg, specialty programs, peer support) to sustain recovery efforts.

Conclusion:
Effective management of alcohol withdrawal in hospital settings requires early recognition of at-risk patients, thoughtful risk stratification, and prompt pharmacologic intervention tailored to withdrawal severity and comorbid conditions. Benzodiazepines remain the mainstay therapy, though phenobarbital shows promise, particularly for resistant or severe cases. Adjunctive alpha-2 agonists help control hyperadrenergic symptoms, but do not replace core GABA-targeted therapies. By integrating nutritional repletion, addressing potential complications, and initiating relapse-prevention strategies, clinicians can reduce both the morbidity of acute withdrawal and the likelihood of future hospitalizations related to alcohol use.

Reference:
Kast KA, Sidelnik SA, Nejad SH, Suzuki J. Management of alcohol withdrawal syndromes in general hospital settings. BMJ 2025;388:e080461. https://doi.org/10.1136/bmj-2024-080461

 

---

Diagnosis and Management of Eosinophilic Esophagitis: Updated ACG Clinical Guideline Summary

14 Jan, 2025 | 13:46h | UTC

Introduction: This summary highlights the updated American College of Gastroenterology (ACG) Clinical Guideline on eosinophilic esophagitis (EoE), a chronic, immune-mediated disease of the esophagus characterized by esophageal eosinophilia and clinical symptoms of esophageal dysfunction. Over the last decade, the incidence and prevalence of EoE have increased significantly. This guideline incorporates new diagnostic strategies, therapeutic advances, and monitoring practices, aiming to improve patient outcomes and minimize disease complications such as strictures, food impactions, and impaired quality of life. The document underscores the importance of assessing both the inflammatory and fibrostenotic components of EoE through endoscopy, histopathology, and symptom evaluation.

Key Recommendations:

• Diagnosis:
  • Diagnose EoE when patients present with symptoms of esophageal dysfunction and at least 15 eosinophils per high-power field (eos/hpf) on esophageal biopsies, after exclusion of other causes of esophageal eosinophilia.
  • Use a systematic scoring tool such as the EoE Endoscopic Reference Score (EREFS) to assess edema, rings, exudates, furrows, and strictures at every endoscopy.
  • Obtain at least six esophageal biopsies from two or more levels (e.g., distal and proximal) to minimize diagnostic miss rates; quantify peak eosinophil counts in each specimen.
• Pharmacologic Therapy:
  1. Proton Pump Inhibitors (PPIs):
     • Consider high-dose PPIs (e.g., twice daily) as a first-line treatment option. Although originally used for acid suppression, PPIs also reduce eotaxin-3 expression and improve esophageal barrier function in EoE.
     • Maintain therapy long term in patients who respond, as discontinuation frequently leads to disease recurrence.
  2. Topical Corticosteroids (Swallowed Steroids):
     • Budesonide or fluticasone can be delivered via specially formulated suspensions/tablets or by swallowing inhaler medication.
     • Expect histologic remission rates of around 60%–70%.
     • Oral/esophageal candidiasis is the most common adverse event. Routine adrenal suppression testing is generally not necessary for short-term use.
  3. Dietary Elimination:
     • Empiric elimination diets (e.g., 2-food or 6-food elimination) help identify specific food triggers. Histologic remission rates can exceed 70%, particularly with the 6-food approach.
     • Less-restrictive diets (e.g., milk-only elimination) may be tried first (the “step-up” approach).
     • Do not rely on currently available skin prick or Ig-based tests to guide elimination diets, as these have poor predictive value for EoE triggers.
  4. Biologic Therapy:
     • Dupilumab (anti–IL-4 receptor alpha) is recommended in adolescents and adults (≥12 years, ≥40 kg) and is now approved for children as young as 1 year (≥15 kg) with moderate to severe, PPI-refractory EoE. Expect significant histologic, endoscopic, and symptom improvements in most patients, along with an overall favorable safety profile.
     • Other biologics (e.g., cendakimab, benralizumab, mepolizumab) remain under investigation; current data are insufficient for routine clinical use.
  5. Esophageal Dilation:
     • Perform endoscopic dilation to treat symptomatic strictures or narrow-caliber esophagi. Dilation reduces dysphagia promptly but does not alter the underlying inflammation.
     • Combine dilation with anti-inflammatory therapy to address the disease’s inflammatory component and help prevent recurrent stricture formation.
• Maintenance and Monitoring:
  • Because EoE is chronic, continue effective therapy over the long term. Abrupt cessation of treatment often leads to relapses in symptoms and inflammation.
  • Evaluate treatment response by assessing symptoms, endoscopic findings (e.g., EREFS), and histopathology (peak eosinophil counts).
  • A target of <15 eos/hpf and near-normal endoscopic appearance (EREFS ≤2) is commonly used to define remission, although some patients aim for histologic normalization.
  • In children, ensure regular assessment of growth, development, and feeding behaviors. Referral to a nutritionist or feeding therapist is recommended if feeding difficulties or failure to thrive are present.

Conclusion: These updated ACG guidelines underscore the importance of a comprehensive, individualized approach to EoE that encompasses diagnosis, treatment of the inflammatory state, dilation of fibrotic strictures, and ongoing monitoring to maintain long-term remission. The introduction of biologics (particularly dupilumab) expands treatment options for patients nonresponsive to PPIs or topical steroids. Clinicians should adopt a structured assessment strategy—integrating clinical history, endoscopic scoring, and histological evaluation—to guide therapy selection, document treatment response, and prevent complications. With improved understanding of disease pathogenesis and evolving therapeutic tools, outcomes for patients with EoE are expected to continue to improve.

Reference: Dellon ES, Muir AB, Katzka DA, Shah SC, Sauer BG, Aceves SS, Furuta GT, Gonsalves N, Hirano I. ACG Clinical Guideline: Diagnosis and Management of Eosinophilic Esophagitis. The American Journal of Gastroenterology. 2025;120(1):31–59. DOI: https://doi.org/10.14309/ajg.0000000000003194

 

---

AGA Clinical Practice Update on Potassium-Competitive Acid Blockers for Foregut Disorders

14 Jan, 2025 | 11:20h | UTC

Introduction: This summary presents the key points of a recently published American Gastroenterological Association (AGA) Clinical Practice Update that reviews the role of potassium-competitive acid blockers (P-CABs) in managing acid-related foregut disorders. P-CABs offer a unique mechanism of action compared with proton pump inhibitors (PPIs) and histamine_2-receptor antagonists, potentially delivering more rapid and prolonged acid suppression. The aim of this review is to provide clinicians with evidence-based guidance on P-CAB use in gastroesophageal reflux disease (GERD), Helicobacter pylori (HP) infection, and peptic ulcer disease (PUD), clarifying their benefits, limitations, and potential place in therapy.

Key Recommendations:

1. Overall Use of P-CABs: Clinicians should generally avoid using P-CABs as first-line therapy for acid-related conditions unless there is proven clinical superiority over PPIs. Factors such as higher costs, more limited availability, and less comprehensive long-term safety data often outweigh the advantages of P-CABs, particularly for milder disease.
2. Cost-Effectiveness: Current U.S. costs for P-CABs may not justify routine first-line use, even if modest clinical benefits exist compared with double-dose PPIs. Long-term data on cost-effectiveness and safety remain limited.
3. Nonerosive GERD: P-CABs are not recommended as initial treatment for heartburn without endoscopic findings (uninvestigated GERD) or nonerosive reflux disease. Clinicians may consider P-CABs for patients who have confirmed acid-related reflux and show inadequate response to twice-daily PPI therapy.
4. On-Demand Therapy: Rapid onset of P-CABs suggests potential utility in on-demand regimens for patients previously responsive to acid suppression. While limited data show efficacy compared to placebo, further trials against PPIs and histamine_2-receptor antagonists are needed before making firm recommendations.
5. Mild Erosive Esophagitis (LA Grade A/B): For Los Angeles classification (LA) grade A/B erosive esophagitis (EE), standard PPIs remain first-line treatment. P-CABs may be an option for patients whose esophagitis persists despite optimal PPI therapy, but initial evidence does not support routine, front-line use.
6. Severe Erosive Esophagitis (LA Grade C/D): In more advanced EE, P-CABs can be considered for healing and maintenance, as some data suggest superior efficacy compared with standard-dose PPI. However, the lack of comparative trials with high-dose PPIs and the higher cost of P-CABs complicate their routine use as first-line therapy in severe disease.
7. HP Eradication: P-CAB–based regimens for H pylori treatment often show higher or noninferior cure rates compared with PPI-based therapies, particularly in the presence of clarithromycin resistance. The more potent and prolonged acid suppression may enhance antibiotic efficacy, supporting the use of P-CABs in most patients with HP infection.
8. Peptic Ulcer Disease Treatment and Prophylaxis: Current evidence indicates that P-CABs are noninferior to PPIs for ulcer healing and prevention of recurrent ulcers in patients requiring aspirin or nonsteroidal anti-inflammatory drugs. However, in light of their higher cost and similar clinical outcomes, P-CABs should not replace PPIs as first-line therapy unless patients fail PPI regimens.
9. Ulcer Bleeding: Although data are preliminary, P-CABs may be useful following endoscopic hemostasis in high-risk ulcer bleeding. Their rapid and potent acid suppression suggests they could match or exceed high-dose PPI efficacy, but more robust comparative trials are needed.

Conclusion: Potassium-competitive acid blockers represent a valuable therapeutic option in selected patients who do not respond adequately to traditional PPIs or who have complex acid-related conditions (such as severe erosive esophagitis or antibiotic-resistant H pylori). While their more rapid onset of action and prolonged effect can be advantageous, the limited availability of long-term safety data, cost considerations, and lack of substantial clinical superiority over standard or double-dose PPIs in many indications currently limit widespread adoption. Further investigations are needed to establish cost-effectiveness, clarify safety profiles, and identify specific patient populations most likely to benefit from P-CABs.

Reference: Patel A, Laine L, Moayyedi P, Wu J. AGA Clinical Practice Update on Integrating Potassium-Competitive Acid Blockers Into Clinical Practice: Expert Review. Gastroenterology. 2024;167(6):1228–1238. https://doi.org/10.1053/j.gastro.2024.06.038

 

---