Opioid, Benzodiazepine and Alcohol Withdrawal Viva

Long Case Viva Defence

Opening statement

"Mrs Clarke is a 61-year-old woman with alcohol dependence and cirrhosis who has taken temazepam nightly for ten years. She was admitted with alcohol withdrawal. The issues are safe withdrawal management in liver disease, combined alcohol and benzodiazepine dependence, and a plan for the benzodiazepine." ^[2]

Examiner questions

Q1: "Which benzodiazepine would you use, given her liver disease?"

"NICE advises considering a benzodiazepine that needs limited liver metabolism, for example lorazepam, starting at a reduced dose and monitoring liver function carefully. Benzodiazepines should be avoided in severe liver impairment. NICE also advises that patients with decompensated liver disease get advice from a professional experienced in managing liver disease." ^{[1] [2]}

Q2: "How does her temazepam change the withdrawal regimen?"

"NICE advises increasing the benzodiazepine dose when alcohol and benzodiazepine dependence coexist. The starting daily dose is the alcohol withdrawal requirement plus the equivalent regularly used benzodiazepine dose, using one benzodiazepine, and inpatient regimens last 2 to 3 weeks or longer." ^[2]

Q3: "She wants to come off benzodiazepines altogether. How?"

"The 2025 joint guideline advises against abrupt discontinuation in patients likely to be physically dependent. It suggests starting with 5 to 10 percent dose reductions every 2 to 4 weeks, typically not exceeding 25 percent every 2 weeks. It suggests considering a switch to a comparable dose of a longer-acting benzodiazepine only for patients without contraindications, such as significant liver dysfunction, which matters in her cirrhosis. It also advises offering psychosocial support." ^[3]