• Corpus ID: 4261161

'I'm Sober, Doctor, Really': Best Biomarkers for Underreported Alcohol Use: When and How to Use Highly Specific Combinations to Assess Withdrawal Risk

@article{Spiegel2008ImSD,
  title={'I'm Sober, Doctor, Really': Best Biomarkers for Underreported Alcohol Use: When and How to Use Highly Specific Combinations to Assess Withdrawal Risk},
  author={David R. Spiegel and Neetu Dhadwal and Frances Gill},
  journal={Current psychiatry},
  year={2008},
  volume={7},
  pages={15}
}

• David R. Spiegel, Neetu Dhadwal, F. Gill
• Published 1 September 2008
• Medicine
• Current psychiatry

Hospitalized patients who are not truthful about their alcohol consumption may be at risk for an unplanned withdraw. Self-reports of alcohol use--such as CAGE and the Alcohol Use Disorders Identification Test (AUDIT)--are valid, inexpensive, and noninvasive, but patients easily can feign results. (1) Biochemical measures are more objective, and combinations of markers are an effective tool to detect recent heavy drinking in the 10% to 25% of patients who underreport alcohol use. (2) [ILLUSTRATION OMITTED] Biochemical measures can detect acute alcohol intoxication and recent prolonged drinking. Because marker levels return to normal after long-term abstinence, ongoing monitoring can help detect a relapse before a patient admits to it. (3) This article presents 3 cases in which biochemical markers helped prevent alcohol withdrawal in patients who denied alcohol abuse. We discuss why we ordered biochemical tests and which combinations provided highly sensitive results. CASE 1 Depression and substance abuse Ms. C, age 39, presents with bleeding gums due to excessive warfarin, which she takes prophylactically for a history of deep vein thrombosis. She is seen by the psychiatric consultation service for depression--which she says she has experienced since "the day I was born"--and substance abuse that includes a history binge drinking. Ms. C says she has stopped drinking and remained abstinent for the past year because she is fearful of further damaging her kidneys. She also denies psychosis. She does not have a history or symptoms of hepatobiliary or hematologic disease. Challenge. Despite Ms. C's self-reported 1 year of sobriety, her history of binge drinking and depression calls for evaluating her alcohol withdrawal risk. Laboratory markers of alcohol abuse are the only means to assess her recent drinking behavior. Discussion. Lab results include serum albumin of 3.4 g/dL, total bilirubin of 0.3 mg/dL, total protein of 6.3 g/dL, asparate aminotranserase (AST) of 13 U/L, alanine aminotransferase (ALT) of 19 U/L, alkaline phosphatase of 136 U/L, and blood ammonia level of 37 [micro]g/dL. Gamma-glutamy transferase (GGT) is elevated at 104 U/L (normal range for women: 0 to 45 U/L). Mean corpuscular volume (MCV) is elevated at 101 fL (normal range 80 to 100 fL). The combination of elevated MCV and GGT has a 95% sensitivity for alcohol abuse. (4) GGT levels become elevated after 24 hours to 2 weeks of heavy alcohol consumption and return to normal within 2 to 6 weeks of abstinence, which allows them to detect binge drinking. MCV takes 6 to 8 weeks of heavy drinking--we which we define as consuming [greater than or equal to]40 grams of alcohol/day (5)--to become elevated and returns to normal within 3 months of abstinence. These data provide evidence that Ms. C recently consumed substantial amounts of alcohol. As a result, we start her on alcohol withdrawal precautions (AWP). Markers of alcohol abuse Biochemical markers commonly used to detect alcohol abuse (Table 1, page 19) include: * blood alcohol level (BAL) * MCV * liver function tests (LETs) such as ALT, AST, and GGT * carbohydrate deficient transferrin (CDT). Table 1 By the numbers: Biomarkers of excessive alcohol consumption Biomarker CDT GGT Blood test 1.3% of total transferrin Women: > 45 U/L Men: abnormal range concentration > 53 U/L Time to 2 to 3 weeks 24 hours to 2 weeks elevation Time to descent 2 to 4 weeks of abstinence 2 to 6 weeks of abstinence to normal levels Dose-response 60 g/d 80 to 200 g/d of alcohol Sensitivity 55% to 90% (a-e) 37% to 85% (b), (f), (g) Relapse 55% to 76% (a), (l), (m) 50% (a), (e) sensitivity Specificity 92% to 97% (a), (b) 18% to 93% (a), (b), (e) Positive 46% to 75% (c), (g) 41 % (g) predictive value Negative 72% to 98% (a), (c), (g) 69% to 92% (a), (e), (g) predictive value Biomarker AST ALT Blood test normal range 10 to 34 U/L 8 to 37 U/L Blood test abnormal range Levels rarely Levels rarely exceed 500 U/L exceed 300 U/L Time to elevation 3 to 7 days 3 to 7 days Time to descent to normal Half-life 12 to hours 24 Half-life 37 to levels 57 hours Dose-response of alcohol [greater than or [greater than or equal to] 40 g/d equal to] 40 g/d Sensitivity AST:ALT ratio > 2:1 has a 70% sensitivity and 92% to 100% specificity for alcoholic-induced liver disease (h-j) Relapse sensitivity Specificity Positive predictive value Negative predictive value MCV Blood test normal range 80 to 100fL Blood test abnormal range > 100fL Time to elevation After 6 weeks Time to descent to normal levels 3 months Dose-response of alcohol [greater than or equal to] 40 g/d Sensitivity 20% to 70% (b) (k) Relapse sensitivity 20% (a),(n) Specificity 64% to 66% (b), (k), (n) Positive predictive value 36% (g) Negative predictive value 67% (g) AST: aspartate aminotransferase; ALT: alanine aminotransferase; CDT: carbohydrate deficient transferrin; GGT: gamma-glutamyl transferase; MCV: mean corpuscular volume Source: For reference citations, see this article on CurrentPaychiatry. …