Highlighting the GRACE-4 Guidelines in Emergency Medicine

Reference: Borgundvaag et al. Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE-4): Alcohol use disorder and cannabinoid hyperemesis syndrome management in the emergency department. AEM May 2024 Date: May 22, 2024 Dr. Bjug Borgundvaag Guest Skeptic: Dr. Bjug Borgundvaag is the Founding Director of the Schwartz/Reisman Emergency Medicine Institute (SREMI), at Sinai Health System. He is a Professor of Emergency Medicine and a Clinician Scientist in the Department of Family and Community Medicine at U of T. Prior to his medical training, he completed a PhD in Pharmacology at U of T. He has been involved in ED-based clinical research examining ways to improve care for patients with alcohol use disorder in the ED for over two decades. This is an SGEM HOP but with a twist. We are not going to do a structured critical appraisal of GRACE4 but rather turn it into an SGEM Xtra. When we combine SGEMHOP with an SGEM Xtra I hope we get some…AMAZING knowledge translation for GRACE4. "The SAEM GRACE program addresses the best practices for the care of the most common chief complaints that can be seen on the tracking board of any emergency department in the country, based upon research and expert consensus. These guidelines are designed with de-implementation as a guiding principle to reasonably reduce wasteful testing, provide explicit criteria to reduce foreseeable risk, and define sensible and prudent medical care." GRACE1: Recurrent, Low-Risk Chest Pain GRACE2: Recurrent, Low-Risk Abdominal Pain GRACE3: Acute Dizziness & Vertigo For this SGEMHOP Xtra combo episode on GRACE4, we are going to give a case scenario, a little background information, ask a clinical question, provide authors’ conclusions, go through the recommendations and a case resolution. Case 1: A patient presents to the ED with nausea, vomiting and some abdominal pain complaining of alcohol withdrawal. He reports that his last drink was 9 hours ago, and he typically consumes 60 oz of spirits/day. He has had prior hospital admissions for the management of alcohol withdrawal, including seizures and one prior episode of delirium tremens. Management: The patient is initiated on a Clinical Institute Withdrawal Assessment (CIWA) protocol and administered intravenous (IV) doses of diazepam hourly for the next 18 hours. There was a 6-hour delay until the first dose of diazepam was administered. Over those 18 hours, his CIWA stubbornly stays at around 18, and by the 15-hour mark, has increased to 21 despite receiving 20mg of diazepam hourly. By the 18-hour mark, he has had a total of 240 mg of diazepam and is getting worse. Clinical Question 1: Is IV phenobarbital, in addition to diazepam, helpful in managing this case of severe alcohol withdrawal? Authors’ Conclusions: There is limited direct high-quality evidence from clinical trials supporting the use of phenobarbital as an adjunct to benzodiazepines for managing moderate to severe AWS in the ED setting. Although the direct prospective evidence comparing these interventions in ED patient populations is limited, the balance between desirable and undesirable effects favours adjunctive phenobarbital over benzodiazepine alone. This is based, in large part, on indirect evidence illustrating the benefits of adjunctive phenobarbital including, but not limited to, reduction on the need for intubation, decreased hospital length of stay, decreased ICU admission and length of stay. Recommendation 1: In adult ED patients (over the age of 18) with moderate to severe alcohol withdrawal, who are being admitted to the hospital we suggest using phenobarbital in addition to benzodiazepines as compared to using benzodiazepines alone. (Conditional recommendation, FOR) [Low to Very Low certainty of evidence] Good practice statement: All patients treated for alcohol withdrawal should be offered follow-up treatment where such treatment is available. Case 1 Resolution: After receiving 240 mg of diazepam over 18 hours with no improvement, the patient was given phenobarbital 5 mg/kg as an infusion. The patient’s symptoms showed significant improvement, and 1 hour later the patient was given an additional 5 mg/kg dose resulting in complete symptom resolution. Case 2: A female patient presents to the ED with moderate alcohol withdrawal. She has consumed 26 oz of vodka a day, for the last four years. She has no history of being admitted to the hospital for the management of alcohol withdrawal syndrome (AWS). Background 2: The patient is treated with diazepam using a symptom-driven approach including hourly CIWA assessments including long-acting benzodiazepines to manage symptoms according to severity. Her AWS resolves over the next 8 hours, and she is ready to be discharged home by the end of your shift. You make a referral to a local addiction medicine service for her to be seen a few days later. Clinical Question 2: Should this patient be offered anti-craving medication upon discharge? Authors’ Conclusions: There is limited high-quality direct evidence on the use of anti-craving medications in the ED for the treatment of AUD. Despite this limitation, the balance of desirable and undesirable effects favours prescribing anti-craving medications in the ED for people with AUD. This is based on indirect evidence demonstrating the effectiveness of naltrexone, acamprosate, and gabapentin in reducing heavy drinking days and increasing abstinence. In addition, these medications are well tolerated with mild side effects. Recommendation 2: In adult ED patients (over the age of 18) with alcohol use disorder, we suggest a prescription for an anti-craving medication for the management of alcohol use disorder for patients who desire alcohol cessation (conditional recommendation, FOR) [Very Low to Low Certainty of Evidence]. Good practice statement: Please see the anti-craving medication algorithm (Figure 4) which was designed to help guide clinicians in the selection of anti-craving medication based upon patient-level factors and the strength of evidence for three medications. Dosage adjustments related to hepatic and renal function can be made at follow-up. Good practice statement: As per the American Society of Addiction Medicine Guidelines clinicians should consider offering patients with AUD supplemental thiamine as part of their ED treatment plan, and should be offered follow-up treatment where such treatment is available. Recommendation 2a: In adult ED patients (over the age of 18) with alcohol use disorder who are not taking opioids, we suggest naltrexone (as compared to no prescription) for the management of alcohol use disorder to prevent return to heavy drinking and/or to reduce heavy drinking (Conditional Recommendation, FOR) [Low Certainty of Evidence]. Good practice statement: A bridging prescription of up to four weeks until follow-up with an addiction medicine physician, primary care physician, or other appropriate health care provider can take place is preferred. Monitoring of liver enzymes should be at the discretion of the provider seeing the patient in follow-up. For patients not treated with long-acting benzodiazepines for AWS in the ED, patients should be advised that sudden cessation of alcohol consumption (as a result of anti-craving medication) may produce acute AWS. These patients should be counselled to slowly taper consumption and seek treatment for AWS management should symptoms occur. Recommendation 2b: In adult ED patients (over the age of 18) with alcohol use disorder, with contraindications to naltrexone, we suggest acamprosate (as compared to no prescription) for the management of alcohol use disorder to prevent return to heavy drinking and/or to reduce heavy drinking (Conditional Recommendation, FOR) [Low Certainty of Evidence]. Good practice statement: A bridging prescription of up to four weeks until follow-up where renal function can be monitored with an addiction medicine physician, primary care physician, or other appropriate health care provider is preferred. Recommendation 2c: In adult ED patients (over the age of 18) with alcohol use disorder, we suggest gabapentin (as compared to no prescription) for the management of alcohol use disorder to reduce heavy drinking days and improve alcohol withdrawal symptoms (Conditional Recommendation, FOR) [Very Low Certainty of Evidence]. Good practice statement: Given the known misuse potential of gabapentin, a bridging prescription, for example less than 2 weeks, is preferable to a long-term prescription. Patients should be cautioned about the sedative effects of gabapentin, and it should be prescribed with caution or avoided altogether in patients who use opioids. In patients with high self-reported withdrawal symptoms when they stop or reduce their alcohol intake, consider prescribing gabapentin in addition to naltrexone or acamprosate. Consider a weekly dispensing interval for gabapentin prescriptions longer than 2 weeks. Case 2 Resolution: The fact that the patient’s AWS was well controlled, and they were comfortable created an environment in which an exploratory conversation about the effects that alcohol consumption at this level was having on the patient’s health was possible. She was interested in becoming abstinent but had tried and failed many times on their own. They had never been treated with anti-craving medications and had never had any specialized additional medicine support for their alcohol use disorder. The patient was offered and accepted 50 mg of naltrexone/day (10-day script), and a referral was made to an addiction medicine clinic for follow-up within a few days. Case 3: A 28-year-old patient with no prior abdominal surgeries presents to the ED with 24 hours of uncontrollable nausea and vomiting. The patient is unable to get comfortable and is in some distress.