The patient in this vignette presents with auditory hallucinations, malaise, and autonomic hyperactivity (e.g., tremor, tachycardia, and irritability), which suggests the diagnosis of alcohol withdrawal. In light of this patient's history of cirrhosis, the best next step in management is a benzodiazepine taper with lorazepam, which is not dependent on hepatic metabolism.
Benzodiazepines are commonly used in the treatment of moderate to severe alcohol withdrawal because benzodiazepines and alcohol allosterically modulate the same GABA-A ligand-gated channel. Diazepam and chlordiazepoxide are the benzodiazepines of choice in most cases; however, in patients with hepatic comorbidities, a benzodiazepine that is not dependent on hepatic metabolism is indicated. These included lorazepam, oxazepam, and temazepam (LOT).
Figure A shows palmar erythema, a clinical finding that can be found in cirrhosis.
Answer 1: Chlordiazepoxide is a long-acting benzodiazepine that is often used to treat alcohol withdrawal. However, as it is dependent on liver metabolism, it is contraindicated in patients with hepatic comorbidities.
Answer 2: Lactulose is a non-absorbable sugar that is used in hepatic encephalopathy to acidify the gut lumen, thereby decreasing ammonia reabsorption. It is not used in the setting of alcohol hallucinosis unless hepatic encephalopathy is suspected.
Answer 3: Midazolam is a short-acting benzodiazepine that is sometimes used to treat alcohol withdrawal. However, as it is dependent on liver metabolism, it is contraindicated in patients with hepatic comorbidities.
Answer 4: Rifamixin is a non-absorbable antibiotic that is used in hepatic encephalopathy to kill bacteria in the gut lumen, thereby decreasing the conversion of dietary protein to ammonia.
Benzodiazepines that are not contraindicated in impaired liver function (e.g., lorazepam, oxazepam, and temazepam) should be used to treat moderate to severe alcohol withdrawal in patients with hepatic comorbidities.