Guideline:
EFNS guideline on the diagnosis and management of alcohol-related seizures
Bibliographic Source(s)
- Brathen G Ben-Menachem E Brodtkorb E Galvin R Garcia-Monco JC Halasz P Hillbom M Leone MA Young AB EFNS Task Force on Diagnosis and Treatment of Alcohol-Related Seizures. EFNS guideline on the diagnosis and management of alcohol-related seizures: report of an EFNS task force. Vienna Austria: European Federation of Neurological Societies (EFNS); 2005. 30 p. [73 references]
Guideline Status
This is the current release of the guideline.
Guideline Category
Diagnosis
Evaluation
Management
Prevention
Treatment
Intended Users
Emergency Medical Technicians/Paramedics
Physicians
Substance Use Disorders Treatment Providers
Guideline Objective(s)
To summarize the current evidence for the diagnosis and management of alcohol-related seizures
Target Population
Individuals with alcohol-related seizures
Interventions and Practices Considered
Diagnosis/Evaluation
- Drinking history
- Questionnaires (e.g. the Alcohol Use Disorders Identification Test [AUDIT] CAGE)
- Biomarkers (carbohydrate-deficient transferrin [CDT] gammaglutamyl transferase [GGT])
- Blood alcohol measurement
- Patient examination and observation (Clinical Institute Withdrawal Assessment Scale [CIWA-Ar])
- Neuroimaging (computed tomography [CT] or magnetic resonance imaging [MRI]) and re-imaging if necessary
- Electroencephalogram (EEG)
Management/Treatment/Prevention
- Prophylactic thiamine therapy
- Hospitalization and observation for at least 24 hours
- Supportive treatment (e.g. calm reassuring atmosphere dim light coffee restriction hydration)
- Benzodiazepines (e.g. diazepam lorazepam) for treatment and primary and secondary seizure prevention
Major Outcomes Considered
- Accuracy sensitivity and specificity of diagnostic tests
- Complications of alcohol overuse
Methods Used to Collect/Select Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
The task force systematically searched MEDLINE (1966 to August 2004) and EMBASE (1974 to May 2004) using the key words alcohol or ethanol or substance withdrawal and seizures or convulsions both directly and as part of a specific Medical Subject Heading (MESH) strategy. Separate MEDLINE and EMBASE searches for papers on biomarkers of alcohol abuse were performed using the search criteria (Biomarkers OR gammaglutamyl transferase OR Carbohydrate-deficient transferrin) AND (seizures OR convulsions). A third set of searches was done for questionnaires for detection of alcohol overuse and withdrawal using the search string (Questionnaire* OR AUDIT OR MAST OR FAST OR MALT OR CAGE) AND (Seizures OR Convulsions).
Searches for systematic reviews and trials were performed in the Cochrane review database and the Cochrane central register of controlled trials The Scottish Intercollegiate Guidelines Network (SIGN) the Agence Nationale d'Accredition et d'Evaluation en Santé the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the US Governmental Agency for Healthcare Research and Quality; all by using the key words from the main search. All these searches were updated in September 2004.
The Task Force searched for articles in English Finnish French German Italian Spanish and the Scandinavian languages. Reference lists of recent papers of high relevance were reviewed. Non-indexed material (e.g. national practice guidelines and national research institute or governmental publications) were collected but not systematically searched for.
The present guidelines are based on data from randomised controlled trials (RCTs) where such information exists. For questions not sufficiently addressed by RCTs other types of articles were reviewed.
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
Evidence Classification Scheme for a Diagnostic Measure
Class I: A prospective study in a broad spectrum of persons with the suspected condition using a "gold standard" for case definition where the test is applied in a blinded evaluation and enabling the assessment of appropriate tests of diagnostic accuracy
Class II: A prospective study of a narrow spectrum of persons with the suspected condition or a well-designed retrospective study of a broad spectrum of persons with an established condition (by "gold standard") compared to a broad spectrum of controls where test is applied in a blinded evaluation and enabling the assessment of appropriate tests of diagnostic accuracy
Class III Evidence provided by a retrospective study where either persons with the established condition or controls are of a narrow spectrum and where test is applied in a blinded evaluation
Class IV: Any design where test is not applied in blinded evaluation OR evidence provided by expert opinion alone or in descriptive case series (without controls)
Evidence Classification Scheme for a Therapeutic Intervention
Class I: An adequately powered prospective randomized controlled clinical trial with masked outcome assessment in a representative population or an adequately powered systematic review of prospective randomized controlled clinical trials with masked outcome assessment in representative populations. The following are required:
- Randomization concealment
- Primary outcome(s) is/are clearly defined
- Exclusion/inclusion criteria are clearly defined
- Adequate accounting for dropouts and crossovers with numbers sufficiently low to have minimal potential for bias
- Relevant baseline characteristics are presented and substantially equivalent among treatment groups or there is appropriate statistical adjustment for differences
Class II: Prospective matched-group cohort study in a representative population with masked outcome assessment that meets a–e above or a randomized controlled trial in a representative population that lacks one criteria a–e
Class III: All other controlled trials (including well-defined natural history controls or patients serving as own controls) in a representative population where outcome assessment is independent of patient treatment
Class IV: Evidence from uncontrolled studies case series case reports or expert opinion
Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence
Papers on health care interventions and diagnostic tests were graded by quality and formed basis for grading of the recommendations (levels A to C) according to the strength of evidence for each recommendation.
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
Consensus was reached by discussions during meetings of the Task Force at European Federation of Neurological Societies (EFNS) congresses and at a separate workshop. The evidence and recommendation levels are graded according to the current guidance (see the "Rating Scheme for the Strength of the Evidence" and the "Rating Scheme for the Strength of the Recommendations" fields). Some important aspects of patient management that lack the evidence required for recommendations have been included; these are marked GPP for "Good Practice Points".
Method for Reaching Consensus
Subsequent to the initial literature search the Task Force arranged a workshop in March 2003 in order to review the literature and obtain consensus on pre-defined central clinical topics. Four members of the Task Force participated to the workshop in which consensus was reached on basis of the strength of the available evidence. The results were then subject to e-mail discussions amongst all members. For several important topics the Task Force did not find sufficient evidence and thus no recommendation is given. Nevertheless important topics that lack evidence are being discussed and the text in these cases reflects the consensus of the Task Force members. No controversies remain in the final document.
Rating Scheme for the Strength of the Recommendations
Rating of Recommendations for a Diagnostic Measure
Level A rating (established as useful/predictive or not useful/predictive) requires at least one convincing class I study or at least two consistent convincing class II studies.
Level B rating (established as probably useful/predictive or not useful/predictive) requires at least one convincing class II study or overwhelming class III evidence.
Level C rating (established as possibly useful/predictive or not useful/predictive) requires at least two convincing class III studies.
Rating of Recommendations for a Therapeutic Intervention
Level A rating (established as effective ineffective or harmful) requires at least one convincing class I study or at least two consistent convincing class II studies.
Level B rating (probably effective ineffective or harmful) requires at least one convincing class II study or overwhelming class III evidence.
Level C rating (possibly effective ineffective or harmful) requires at least two convincing class III studies.
Good Practice Points (GPPs) Where there was lack of evidence but consensus was clear the Task Force members have stated their opinion as good practice points
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation
The guidelines were validated according to the European Federation of Neurological Societies (EFNS) criteria (Hughes RAC Barnes MP Baron J Brainin M [2001]. Guidance for the preparation of neurological management guidelines by EFNS scientific task forces. Eur J Neurol 8:549-550).
Major Recommendations
The levels of evidence (class I-IV) supporting the recommendations and ratings of recommendations (A-C Good Practice Point [GPP]) are defined at the end of the "Major Recommendations" field.
Diagnosis of Alcohol-Related Seizures
History Taking
A good drinking history includes both the quantity and frequency of alcohol intake and changes in drinking pattern at least during the previous five days as well as the time of the last alcohol intake (GPP).
Questionnaires
Questionnaires offer high diagnostic accuracy for alcohol overuse (level A recommendation). To identify patients with alcohol-related seizures and binge drinking brief versions of the Alcohol Use Disorders Identification Test (AUDIT) are recommended as they are accurate and easy to use in busy clinical settings (level A recommendation).
Biomarkers
Carbohydrate-deficient transferrin (CDT) and gammaglutamyl transferase (GGT) have a potential to support a clinical suspicion of alcohol overuse when the drinking history is inconclusive (level A recommendation). Due to poor accuracy in unselected populations biomarkers should not be applied as general screening instruments (level C recommendation).
As the current intoxication level is important information with potential treatment consequences blood alcohol should be measured in patients with suspected alcohol-related seizures (GPP).
Patient Examination and Observation
More than 90% of alcohol withdrawal seizures occur within 48 hours of cessation of a prolonged drinking bout. Patients should be observed in hospital for at least 24 hours after which a clinical risk assessment should be made with respect to development of symptoms of alcohol withdrawal (GPP).
The Clinical Institute Withdrawal Assessment (CIWA) questionnaire can be applied to grade the severity of withdrawal symptoms and give support to the decision on whether to keep or discharge the patient (level A recommendation).
Neuroimaging
Although it may seem obvious that a given seizure is alcohol-related if it is a first known seizure the patient should have brain imaging (computed tomography [CT] or magnetic resonance imaging [MRI]) without and with contrast (level C recommendation).
When patients present repeatedly with clinically typical alcohol-related seizures re-imaging is not necessary but changes in seizure type and frequency seizure occurrence more than 48 hours after cessation of drinking or other unusual features should prompt repeat neuroimaging (GPP).
Electroencephalography (EEG)
EEG should be recorded after a first seizure. Subsequent to repeated alcohol withdrawal seizures (AWS) EEG is considered necessary only if an alternative aetiology is suspected (level C recommendation).
Patient Management
Thiamine Therapy
Before starting any carbohydrate containing fluids or food patients presenting with known or suspected alcohol overuse should be given prophylactic thiamine in the emergency room (level B recommendation).
For the treatment of imminent or manifest Wernicke's encephalopathy uncontrolled trials and empirical clinical practice suggest a daily dose of at least 200 mg thiamine parenterally for minimum 3 to 5 days. In the guideline developers' experience patients with Wernicke's encephalopathy may benefit from continued treatment for more than two weeks (GPP).
Should All Patients with Symptoms of Alcohol Withdrawal Be Offered Seizure Prophylactic Treatment?
For patients with no history of withdrawal seizures and mild to moderate withdrawal symptoms routine seizure preventive treatment is not recommended (level B recommendation). Patients with severe alcohol withdrawal symptoms regardless of seizure occurrence should be treated pharmacologically (level C recommendation).
Drug Options for Primary Prevention of Alcohol Withdrawal Seizures
When pharmacological treatment is necessary benzodiazepines should be chosen for the primary prevention of seizures in a person with alcohol withdrawal as well as for treatment of the alcohol withdrawal syndrome. The drugs of choice are lorazepam and diazepam. Although lorazepam has some pharmacological advantages to diazepam the differences are minor and as intravenous (i.v.) lorazepam is largely unavailable in Europe diazepam is recommended. Other drugs for detoxification should only be considered as add-ons (level A recommendation).
Secondary Prevention of Withdrawal Seizures
Benzodiazepines should be used for the secondary prevention of AWS (level A recommendation). Phenytoin is not recommended for prevention of AWS recurrence (level A recommendation). The efficacy of other antiepileptics for secondary prevention of AWS is undocumented.
Alcohol-Related Status Epilepticus
For the initial treatment of alcohol-related status epilepticus i.v. lorazepam is safe and efficacious. When unavailable i.v. diazepam is a good alternative (level A recommendation).
How Much Alcohol Can a Patient with Epilepsy Safely Consume?
For the majority of patients with partial epilepsy and controlled seizures and in the absence of any history of alcohol overuse an intake of 1 to 3 standard alcohol units 1 to 3 times a week is safe (level B recommendation).
Definitions:
Evidence Classification Scheme for a Diagnostic Measure
Class I: A prospective study in a broad spectrum of persons with the suspected condition using a "gold standard" for case definition where the test is applied in a blinded evaluation and enabling the assessment of appropriate tests of diagnostic accuracy
Class II: A prospective study of a narrow spectrum of persons with the suspected condition or a well-designed retrospective study of a broad spectrum of persons with an established condition (by "gold standard") compared to a broad spectrum of controls where test is applied in a blinded evaluation and enabling the assessment of appropriate tests of diagnostic accuracy
Class III: Evidence provided by a retrospective study where either persons with the established condition or controls are of a narrow spectrum and where test is applied in a blinded evaluation
Class IV: Any design where test is not applied in blinded evaluation OR evidence provided by expert opinion alone or in descriptive case series (without controls)
Evidence Classification Scheme for a Therapeutic Intervention
Class I: An adequately powered prospective randomized controlled clinical trial with masked outcome assessment in a representative population or an adequately powered systematic review of prospective randomized controlled clinical trials with masked outcome assessment in representative populations. The following are required:
- Randomization concealment
- Primary outcome(s) is/are clearly defined
- Exclusion/inclusion criteria are clearly defined
- Adequate accounting for dropouts and crossovers with numbers sufficiently low to have minimal potential for bias
- Relevant baseline characteristics are presented and substantially equivalent among treatment groups or there is appropriate statistical adjustment for differences
Class II: Prospective matched-group cohort study in a representative population with masked outcome assessment that meets a–e above or a randomized controlled trial in a representative population that lacks one criteria a–e
Class III: All other controlled trials (including well-defined natural history controls or patients serving as own controls) in a representative population where outcome assessment is independent of patient treatment
Class IV: Evidence from uncontrolled studies case series case reports or expert opinion
Rating of Recommendations for a Diagnostic Measure
Level A rating (established as useful/predictive or not useful/predictive) requires at least one convincing class I study or at least two consistent convincing class II studies.
Level B rating (established as probably useful/predictive or not useful/predictive) requires at least one convincing class II study or overwhelming class III evidence.
Level C rating (established as possibly useful/predictive or not useful/predictive) requires at least two convincing class III studies.
Rating of Recommendations for a Therapeutic Intervention
Level A rating (established as effective ineffective or harmful) requires at least one convincing class I study or at least two consistent convincing class II studies.
Level B rating (probably effective ineffective or harmful) requires at least one convincing class II study or overwhelming class III evidence.
Level C rating (possibly effective ineffective or harmful) requires at least two convincing class III studies.
Good Practice Points (GPPs) Important aspects of patient management lacking the evidence required for making a recommendation were marked good practice points.
Clinical Algorithm(s)
None provided
Type of Evidence supporting the Recommendations
The type of supporting evidence is identified and graded for selected recommendations (see "Major Recommendations").
Potential Benefits
Appropriate diagnosis and management of alcohol-related seizures
Potential Harms
Adverse Effects of Medications
Benzodiazepines with rapid onset of action (e.g. lorazepam diazepam) seem to have higher overuse potential than those with slower onset of action.
Qualifying Statements
- This guideline provides the view of an expert task force appointed by the Scientific Committee of the European Federation of Neurological Societies (EFNS). It represents a peer-reviewed statement of minimum desirable standards for the guidance of practice based on the best available evidence. It is not intended to have legally binding implications in individual cases.
- Despite being a considerable problem in neurological practice and responsible for one third of seizure-related admissions there is little consensus as to the optimal investigation and management of alcohol related seizures. Furthermore different treatment traditions and policies exist and vary from country to country.
Description of Implementation Strategy
The European Federation of Neurological Societies has a mailing list and all guideline papers go to national societies national ministries of health World Health Organisation European Union and a number of other destinations. Corporate support is recruited to buy large numbers of reprints of the guideline papers and permission is given to sponsoring companies to distribute the guideline papers from their commercial channels provided there is no advertising attached.
Implementation Tools
Resources
Staff Training/Competency Material
For information about availability see the "Availability of Companion Documents" and "Patient Resources" fields below.
IOM Care Need
Getting Better
IOM Domain
Effectiveness
Timeliness
Bibliographic Source(s)
- Brathen G Ben-Menachem E Brodtkorb E Galvin R Garcia-Monco JC Halasz P Hillbom M Leone MA Young AB EFNS Task Force on Diagnosis and Treatment of Alcohol-Related Seizures. EFNS guideline on the diagnosis and management of alcohol-related seizures: report of an EFNS task force. Vienna Austria: European Federation of Neurological Societies (EFNS); 2005. 30 p. [73 references]
Adaptation
Not applicable: The guideline was not adapted from another source.
Source(s) of Funding
European Federation of Neurological Societies
Guideline Committee
European Federation of Neurological Societies Task Force on Diagnosis and Treatment of Alcohol-Related Seizures
Composition of Group that Authored the Guideline
Task Force Members: Geir Bråthen (Chair) Department of Neurology and Clinical Neurophysiology Trondheim University Hospital N 7006 Trondheim Norway; Elinor Ben-Menachem Institute of Clinical Neuroscience SU/Sahlgrenska Hospital S-41345 Gothenburg Sweden; Eylert Brodtkorb Department of Neurology and Clinical Neurophysiology Trondheim University Hospital N 7006 Trondheim Norway; Roderick Galvin Department of Neurology Cork University Hospital Wilton Cork Ireland; Juan Carlos Garcia-Monco Servicio de Neurologia Hospital de Galdacano 48960 Galdacano (Vizcaya) Spain; Peter Halasz National Institute of Psychiatry and Neurology Epilepsy Center H-1021 Budapest Hungary; Matti Hillbom Department of Neurology Oulu University Hospital SF-90220 Oulu Finland; Maurizio A. Leone Clinica Neurologica Ospedale Maggiore della Carità C. Mazzini 18 28100 Novara Italy; Alasdair B. Young Castle Craig Hospital Blyth Bridge West Linton Peebleshire EH46 7DH UK
Financial Disclosures/Conflicts of Interest
None of the authors report conflicting interests.
Guideline Status
This is the current release of the guideline.
Guideline Availability
Electronic copies: Available to registered users from the European Federation of Neurological Societies Web site.
Print copies: Available from Dr Geir Bråthen Department of Neurology and Clinical Neurophysiology Trondheim University Hospital N-7006 Trondheim Norway; Phone: +47 72576006; Fax: +47 7257773; E-mail: geir.brathen@ntnu.no
Availability of Companion Documents
The following are available:
- Brainin M Barnes M Baron JC Gilhus NE Hughes R Selmaj K Waldemar G; Guideline Standards Subcommittee of the EFNS Scientific Committee. Guidance for the preparation of neurological management guidelines by EFNS scientific task forces – revised recommendations 2004. Eur J Neurol. 2004 Sep;11(9):577-81. Electronic copies: Available in Portable Document Format (PDF) from the European Federation of Neurological Societies Web site.
- Guideline papers. European Federation of Neurological Societies. Electronic copies: Available from the European Federation of Neurological Societies Web site.
- Continuing Medical Education questions available from the European Journal of Neurology Web site.
- Questionnaires for detection of alcohol overuse and the Addiction Research Foundation Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) are available from the European Federation of Neurological Societies Web site.
Patient Resources
None available
NGC STATUS
This NGC summary was completed by ECRI on December 5 2006. The information was verified by the guideline developer on December 29 2006.
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