Serum creatine kinase activity differentiates alcohol syndromes of dependence, withdrawal and delirium tremens.

Previous reports described significant differences in serum creatine kinase (CK) activity in bipolar disorder and various forms of depression. The comorbidity of depression and alcohol syndromes was also widely described. We aim to examine potential differences in serum CK level in different alcohol-related syndromes. We assessed morning serum CK activity in 114 inpatients, diagnosed by the Structured Clinical Interview for DSM-IV: Fifty-five subjects with alcohol dependence, 28 with alcohol withdrawal and 31 with delirium tremens (DT's). We found low normal CK activity for the alcohol dependence, higher for alcohol withdrawal and the highest for DT's. Peripheral CK activity of four patients that were admitted during each of the three phases showed similar pattern. These findings may be related to enhanced dopamine activity in alcohol dependence and conversely, to a significant decrease in dopamine activity during withdrawal syndromes. We suggest a supplementary simple laboratory tool for the detection of alcohol-related states.

Phosphatidylethanol as a sensitive and specific biomarker: comparison with gamma-glutamyl transpeptidase, mean corpuscular volume and carbohydrate-deficient transferrin.

Phosphatidylethanol (PEth), a direct ethanol metabolite, is detectable in blood for more than 2 weeks after sustained ethanol intake. Our aim was to assess the usefulness of PEth [comparing sensitivity, specificity and the area under the curve (AUC)] as compared with carbohydrate-deficient transferrin (CDT), gamma-glutamyl transpeptidase (GGT) and mean corpuscular volume (MCV), calculating the results from sober patients against those from alcohol-dependent patients during withdrawal. Fifty-six alcohol-dependent patients (ICD-10 F 10.25) in detoxification, age 43 years, GGT 81 U/l, MCV 96.4 fl, %CDT 4.2, 1400 g ethanol intake in the last 7 days (median), were included in the study. Over the time of 1 year, 52 samples from 35 sober forensic psychiatric addicted in-patients [age 34 years, GGT 16 U/l, MCV 91 fl, CDT 0.5 (median)] in a closed ward were drawn and used for comparison . PEth was measured in heparinized whole blood with a high-performance liquid chromatography method. GGT, MCV and %CDT were measured using routine methods. A receiver operating characteristic curve analysis was carried out, with 'current drinking status' (sober/drinking) as the state variable and PEth, MCV, GGT and CDT as test variables. The resulting AUC was 0.974 (P < 0.0001, confidence interval 0.932-1.016) for PEth. At a cut-off of 0.36 micromol/l, the sensitivity was 94.5% and specificity 100%. The AUC for CDT, GGT and MCV were 0.931, 0.894 and 0.883, respectively. A significant Spearman's rank correlation was found between PEth and GGT (r = 0.739), CDT (r = 0.643), MVC (r = 0.639) and grams of ethanol consumed in the last 7 days (r = 0.802). Our data suggest that PEth has potential to be a sensitive and specific biomarker, having been found in previous studies to indicate longer lasting intake of higher amounts of alcohol.

DBH*444G/A polymorphism of the dopamine-beta-hydroxylase gene is associated with alcoholism but not with severe alcohol withdrawal symptoms.

As the enzyme dopamine-beta-hydroxylase (DbetaH) converts dopamine to norepinephrine and both transmitters seem to be involved in the pathology of alcoholism and severe alcohol withdrawal symptoms, the gene encoding DbetaH (DBH) was applied to explore the genetic background of alcoholism and severe withdrawal symptoms. 102 healthy control subjects and 208 alcoholics, including 97 patients with a history of mild withdrawal symptoms, 57 with a history of alcohol withdrawal seizure (AWS) and 82 with a history of delirium tremens (DT) were genotyped for the DBH*444G/A polymorphism revealing a significantly elevated frequency of genotypes carrying the A-allele (p = 0.02; after Bonferroni adjustment for multiple tests) in alcoholics compared to healthy controls. Frequencies of alleles and genotypes of individuals with mild withdrawal symptoms did not differ significantly from those of patients with DT or AWS.

Gender difference in the pancreatic trypsinogen response to ethanol withdrawal in rat pups.

This study was designed to examine the effects of ethanol withdrawal on offspring rats that consumed ethanol during gestation and lactation, in order to examine whether there was an improvement in pancreatic trypsinogen and lipase activities at 2 months postpartum with respect to offspring that fed on ethanol until death. A second purpose for our study was to determine if a folic acid supplement during gestation and lactation was sufficient or insufficient to reverse the negative effects of ethanol consumption. Both genders were used with the aim of investigating any differential pancreatic behaviour. The animals were randomized into five groups: the control group (CG) received water and a basic rat diet during pregnancy, lactation and growth; the ethanol group (EG) was fed an ethanol diet during pregnancy, the suckling period and growth until death; the ethanol-water group's (E+WG) ethanol was eliminated after lactation; The ethanol-folic acid group (E+FG) received a folic acid supplemented diet during pregnancy and the suckling period and in the ethanol+folic acid group (E+FG+FG) this supplementation continued during growth. Our results showed that ethanol administration or ethanol withdrawal did not significantly alter lipase activity in the pancreas. Ethanol administration decreased trypsinogen levels in the pancreas of males and females. However, in males, as opposed to females, the withdrawal of ethanol did not recover the values of pancreatic trypsinogen content, nor did a folic acid supplementation significantly alter the parameters we studied. Our treatment produced no effect on lipase levels. There was a gender-related difference in pancreatic trypsinogen content, the implication being that in future all results on exocrine pancreas function in male and female animals should be analysed separately.

Association analyses between polymorphisms of the phase II detoxification enzymes (GSTM1, NQO1, NQO2) and alcohol withdrawal symptoms.

BACKGROUND: NRH-quinone oxidoreductase 2 (NQO2) along with glutathione S-transferase M1 (GSTM1) and NAD(P)H-quinone oxidoreductase 1 (NQO1), which is involved in phase II detoxification reactions, is thought to be important for detoxification of catechol o-quinones in the central nervous system. Our previous study revealed that the human NQO2 gene is highly polymorphic. In this study, we investigated a possible association between polymorphisms of the GSTM1, NQO1, and NQO2 genes and alcohol withdrawal symptoms such as delirium tremens, hallucination, and seizure. METHODS: A total of 247 Japanese male alcoholic patients with alcohol withdrawal symptoms or without the symptoms, and 134 age-matched Japanese male controls (nonhabitual drinkers), were examined by using polymerase chain reaction (PCR), PCR restriction fragment length polymorphism, PCR-based single-strand conformational change polymorphism, and PCR direct sequencing analyses. RESULTS A significant difference was found between alcoholic patients and controls in genotype frequency at an insertion/deletion site in the promoter region of the NQO2 gene (p = 0.0014). The frequency of the homozygous genotype for the D allele at this locus was significantly higher in delirium tremens-positive patients (p = 0.0004) and in hallucination-positive patients (p = 0.0001), and in patients displaying both delirium tremens and hallucination (p = 0.0002), than in controls. The values were still significant after Bonferroni correction. On the other hand, no significant difference was detected for allele frequencies or genotype frequencies for the other polymorphic loci of the NQO2 gene. Moreover, GSTM1 gene deletion and missense mutation (Pro187Ser) of the NQO1 gene showed no significant association with alcohol withdrawal symptoms. CONCLUSION: Present data suggest that an insertion/deletion polymorphism in the promoter region of the NQO2 gene plays an important role in the pathogenesis of alcoholism and alcohol withdrawal symptoms.

Chronic ethanol treatment leads to increased ornithine decarboxylase activity: implications for a role of polyamines in ethanol dependence and withdrawal.

Recent research has focused on the N-methyl-D-aspartate receptor system as a major site of ethanol action in the brain and specifically on compensatory changes in the expression of the polyamine-sensitive NR2B subunit. Therefore, we examined the effects of chronic ethanol treatment on polyamine homeostasis in the rat brain. Wistar rats were made dependent by ethanol vapor inhalation. This caused a rise in hippocampal ornithine decarboxylase (ODC) activity that was correlated with the appearance of physiological dependence. ODC activity returned to control levels within 3 days of ethanol withdrawal. Enzyme activity also increased in the cerebral cortex, striatum, and cerebellum of the ethanol-dependent rats. The concentration of the polyamines (putrescine, spermidine, and spermine) in the hippocampus was increased in ethanol-dependent rats. Injection of the ODC inhibitor, alpha-difluoromethylornithine (500 mg/kg) at the onset of withdrawal resulted in a significant reduction in the severity of withdrawal behaviors. The level of ODC activity and the severity of withdrawal behaviors were positively correlated. Perturbed polyamine homeostasis may represent an important molecular component in the initiation of ethanol withdrawal behaviors in the ethanol-dependent rat.

Possible allelic association of a tyrosine hydroxylase polymorphism with vulnerability to alcohol-withdrawal delirium.

Recently, an association has been reported between schizophrenia and a rare allele containing 10-repeats (A10) of a polymorphic tetranucleotide motif in the first intron of the tyrosine hydroxylase (TH) gene. The present association analysis tested the hypothesis that the A10 candidate allele confers vulnerability to alcohol-withdrawal delirium with visual hallucinations. The genotype of the TH tetranucleotide polymorphism was assessed in 204 German controls and 311 German alcohol-dependent subjects, including 63 alcoholics with a history of visual hallucinations during withdrawal delirium. The frequency of the A10 allele was significantly increased in the alcoholics with withdrawal delirium (3.2%) compared with that in the controls (0.5%; Fisher's exact test: P = 0.03, two-tailed; OR (A10+) = 6.85, 95% confidence interval: 1.52-30.79). The possible allelic association suggests that allelic variation at the TH locus mediates vulnerability to alcohol-withdrawal delirium in a small proportion of alcohol-dependent subjects.

Effects of abstinence and family history for alcoholism on platelet adenylyl cyclase activity.

Platelet adenylyl cyclase (AC) activity was measured in 32 alcohol-dependent subjects and 27 control subjects who were categorized as either family history-positive (FHP) or family history-negative (FHN) for alcoholism. The interview and blood sample collections were performed shortly after cessation of heavy drinking in the alcoholic group, and repeat blood samples were obtained at the end of the first and second weeks of monitored abstinence. Control subjects received the same interview and provided blood samples at the time of the interview. When subjects were not segregated for FHP or FHN status, there were no statistically significant differences in basal, cesium fluoride (CsF)-, or forskolin-stimulated mean AC activities between the controls and the alcoholics, at study entry or with 1 or 2 weeks of abstinence. On the other hand, over the 2-week course of sobriety from heavy drinking, the CsF-stimulated AC activity of FHP alcohol-dependent subjects decreased significantly (p = 0.03). FHP alcohol-dependent subjects after 2 weeks of sobriety had significantly lower mean CsF-stimulated AC activity than FHN controls (p = 0.04), whereas the FHN alcoholic subjects' CsF-stimulated AC activity did not differ significantly from FHN controls at this point in time. When all subjects were pooled and then categorized as either FHP or FHN, there was a significant difference in mean CsF-stimulated AC activity (p = 0.02) between the FHP and FHN subject groups. Genetic factors and abstinence appear to have roles in determining low platelet AC activity in alcoholic and nonalcoholic subjects. CsF-stimulated platelet AC activity, in particular, appears to act as a trait marker for a genetic vulnerability to developing alcoholism, but recent heavy drinking in male alcoholics is a factor that can mask differences between FHP and FHN subjects.

Activity of the adenylyl cyclase in lymphocytes of male alcoholic patients is state dependent.

A decreased basal and/or stimulated activity of the G-protein/adenylyl cyclase (AC) system in peripheral blood cells has been proposed to represent a trait marker for alcoholism. However, AC activity may underlie state-dependent changes, which may impair a proper interpretation of AC activity measurements. Our study examined systematically the AC activity in peripheral lymphocytes of 73 male alcohol-dependent patients (according to DSM-IV criteria) at three different time points of measurement during the clinical course of detoxification (day 0 = at admission, while still ethanol-affected; day 2 = at the presumed peak of withdrawal symptoms; day E = after detoxification). Basal and stimulated (with GTPgammaS and forskolin) AC activities were measured. AC activities were compared to those of a control group of 44 healthy male age-matched volunteers. As our main finding, we detected a significant decrease in AC activity from day 0 to day 2 (during withdrawal), with lowered AC activities in a vast majority of patients. This effect resolved after detoxification, as AC activities showed a significant increase from day 2 to E. No significant difference was detected between day 0 and E in AC activities of the patients. Compared with controls, AC activities in patients were significantly lower at day 2, but not at day 0 and E. Taken together, our results indicate rapid and marked state-dependent changes of AC activities in alcohol-dependent patients during the course of detoxification. For an adequate interpretation of AC activities in alcoholic patients, their clinical status must be taken into consideration.

Blood phosphatidylethanol as a marker of alcohol abuse: levels in alcoholic males during withdrawal.

Phosphatidylethanol (PEth) is formed only in the presence of ethanol, via the action of phospholipase D. We studied PEth in blood as a possible marker of alcohol abuse in 15 male alcoholics admitted for detoxification. Blood was drawn on the first day after admission and up to 28 days thereafter. PEth in whole blood was 13.2 +/- 2.2 mumol liter-1 (mean +/- SE) at first sampling and remained detectable up to 14 days after admission. Blood ethanol was 0 on the morning after admission. The time courses of PEth disappearance varied among individuals. No PEth could be found in blood of control persons who had abstained from ethanol for 4 days. Levels of PEth and carbohydrate-deficient transferrin or gamma-glutamyltranspeptidase did not correlate. Its high specificity and prolonged detectability suggest PEth in blood as a marker of recent alcohol abuse.

Alcohol dependence: is carbohydrate-deficient transferrin a marker for alcohol intake?

We investigated %CDT (carbohydrate-deficient transferrin) in 92 ethanol-intoxicated alcohol-dependent patients after consecutive admission to hospital and followed the for 28 days under controlled conditions. At admission, 63% (58 patients) showed elevated CDT (> 2.5%) and 34 patients (37%) had normal CDT levels (< 2.5%). No correlation of the %CDT values to alcohol-related disabilities, severity of the withdrawal syndrome, alcohol-drinking pattern before admission, or several other factors was found. The sensitivity of GGT (gamma-glutamyl transferase) was 58% for the same group of patients. Levels of %CDT decreased during the 28 days following abstinence, whereby we could separate four statistically different groups of "CDT decrease'. In two of these groups, comprising most of the cases studied, normal %CDT levels were reached after 14 days of abstinence. Those patients with %CDT levels exceeding the upper normal level after 14 days of sobriety, showed a decrease during the following 14 days to levels of 2.55-2.61%.

Effects of chronic administration and subsequent withdrawal of ethanol-containing liquid diet on rat liver tryptophan pyrrolase and tryptophan metabolism.

An investigation of the effects of chronic administration of ethanol by the liquid diet procedure and its subsequent withdrawal on tryptophan (Trp) metabolism and disposition was performed in rats. Treatment with the control liquid diet caused an enhancement of liver Trp pyrrolase activity and mRNA abundance. These effects are not due to the starvation associated with this feeding procedure, because they occur in rats maintained on the liquid diet ad libitum. Chronic ethanol administration in the liquid diet did not further influence the above increased expression of Trp pyrrolase mRNA but caused inhibition of pyrrolase activity in competition with the effects of the diet. The control liquid diet decreased liver Trp concentration, but exerted no significant effects on other aspects of Trp disposition. The most striking and robust finding was a highly significant elevation in both Trp pyrrolase activity and mRNA expression at 7 h following discontinuation of ethanol availability, at which time there were demonstrable behavioural signs of ethanol withdrawal. The increase in Trp pyrrolase mRNA during alcohol withdrawal may be caused by corticosterone, whose circulating concentration was also increased. The changes in Trp pyrrolase activity during ethanol withdrawal were associated with significant alterations in Trp disposition including decreased brain Trp concentration and 5-hydroxytryptamine synthesis and turnover. These alterations may play a pivotal role in the behavioural manifestations of ethanol withdrawal including the hyperexcitement underlying audiogenic seizures. We suggest that rat Trp pyrrolase gene regulation may be an important biological determinant of the ethanol withdrawal syndrome and requires further study, and that the use of the liquid diet procedure in Trp metabolic studies requires inclusion of adequate controls and special attention to the effects of the liquid diet itself.

Decrease in cytochrome P4502E1 as assessed by the rate of chlorzoxazone hydroxylation in alcoholics during the withdrawal phase.

To evaluate cytochrome P4502E1 (CYP2E1) induction in alcoholics, the ratio of the concentrations of 6-hydroxychlorzoxazone (6-OH-CHZ) and chlorzoxazone (CHZ) was measured in blood 2 hr after CHZ ingestion using a HPLC method. This ratio was determined in controls and in alcoholic patients after 1, 2, 3, 4, 5, 8, and 21 days withdrawal. It was found to be 0.34 +/- 0.03 in 30 controls and 1.05 +/- 0.14 in 41 alcoholic patients within 2 days following ethanol withdrawal. This ratio decreased rapidly during withdrawal as attested by the short half-life of CYP2E1, which was found to be 2.5 days. Patients tested for CHZ metabolism after 8 or 21 days alcohol abstinence displayed the same ratio as controls [0.35 +/- 0.03 (n = 28) and 0.31 +/- 0.03 (n = 34), respectively]. No correlation was observed between gamma-glutamyltransferase, carbohydrate-deficient transferrin values, the amount of alcohol consumed/day, and the 6-OH-CHZ/CHZ ratio. There was no influence of smoking on the rate of CHZ hydroxylation, because smokers displayed the same ratio as nonsmokers [0.33 +/- 0.025 (n = 62) and 0.33 +/- 0.02 (n = 30), respectively]. The CHZ hydroxylation ratio seems to be a good reflection of the hepatic and extrahepatic CYP2E1 activity in humans.

[Clinical and laboratory differentiation of alcohol withdrawal syndrome ("predelirium") and alcoholic delirium]. / Zur klinischen und labortechnischen Differenzierung des Alkoholentzugssyndroms ("Prädelir") und des Alkoholdelirs.

In a retrospective study, data from 99 male and female inpatients with alcohol withdrawal syndrome or alcohol withdrawal delirium, treated between 1977 and 1987, were analyzed. DSM-III criteria were used to assign the diagnosis of either withdrawal delirium (with obligatory clouding of consciousness) or alcohol withdrawal syndrome (without disturbances of consciousness and/or perception). No statistically significant differences between the two groups were found with respect to the red and white blood count, liver enzymes, and electrolytes. Significant differences were found in calcium levels, lymphocyte counts, and in electrophoresis. However, these differences are of no use for diagnostic purpose. Moreover, they are unspecific with respect to etiology. Hence, the distinction between alcohol withdrawal syndrome and alcohol withdrawal delirium can only be made clinically, i.e., it is dependent on the presence or absence of a clouded consciousness. This is in line with the findings published by other investigators. In the light of our metabolic findings, alcohol withdrawal syndrome and alcohol withdrawal delirium represent the two extremes of a continuum rather than two separate nosological entities.

[Objective criteria of the severity of the alcohol abstinence syndrome and delirium]. / Ob''ektivnye kriterii tiazhesti techeniia alkogol'nogo abstinentnogo sindroma i deliriia.

Overall 467 male patients suffering from stage II and stage II-III chronic alcoholism were examined. Of these, 80 patients (17.1%) were with the abstinent syndrome, 66 (14.1%) had the abstinent convulsive syndrome, 251 (53.8%) were with alcoholic delirium and 80 (14.9%) making up a control group were in a state of remission. Noticeable disorders were revealed in enzymatic activity of the liver (hyperfermentemia) coupled with characteristic changes in proteolytic activity. The degree of disorders in enzymic function of the liver and of the proteolytic system correlates with the severity of the psychopathological syndrome, which suggests the existence of the common component underlying the development of the pathogenetic mechanism in abstinent patients and in those with alcoholic delirium. The alcoholic abstinent syndrome and delirium are stages of the common pathological process.

Morphine influence on adenylate cyclase activity in peripheral blood lymphocytes of alcoholic patients.

The effect of morphine on adenylate cyclase activity in lymphocytes was tested in 20 normal controls, 16 alcoholics in withdrawal and 9 sober alcoholics. Alcoholics in withdrawal were characterized by a significantly increased stimulatory effect of morphine, whereas sober alcoholics showed an inhibitory effect. The morphine effect was abolished by naloxone and correlated with the severity of withdrawal and alcohol intoxication.

[Decrease in the concentration of leukocyte acetylation coenzyme associated with vitamin precursor deficiency in patients with alcoholic delirium]. / Umen'shenie soderzhaniia kofermenta atsetilirovaniia leikotsitov v sviazi s nedostatochnost'iu vitaminnogo predshestvennika u bol'nykh alkogol'nym deliriem.

Sixty-three patients with the typical variant of delirium tremens were examined. The results showed a marked reduction (by 8.7 times) in levels of coenzyme A (CoA) in leukocytes, which was indicative of deficiency of the coenzymic form of pantothenic acid (PA). Changes in CoA concentrations in leukocytes observed at the height of psychosis in patients with alcoholic delirium as compared to other parameters of PA metabolism have great significance for the assessment of vitamin metabolism. PA deficiency was more expressed in cases of long-standing and massive alcoholization which induces an earlier development of psychosis. CoA levels in leukocytes may be used as a parameter of detoxication processes in patients with delirium tremens. The data obtained are considered as indication for administration of PA drugs in combined detoxifying therapy of alcoholic psychoses.

The relationship between depression and the dexamethasone suppression test following alcohol withdrawal in a psychiatric population.

The authors administered at least one dexamethasone suppression test (DST) and Hamilton Rating Scale for Depression (HRSD) simultaneously to 30 psychiatric inpatients following detoxification from alcohol. Twenty-five of these were also interviewed using the NIMH Diagnostic Interview Schedule (DIS). Fifteen patients had two or three sequential DSTs at weekly intervals. Seven of the patients were clinically diagnosed as having a major depressive episode based on close observation over 2 to 4 inpatient weeks free of psychotropic medications. Fifty-eight percent of the initial cortisol determinations with the first 2 weeks showed nonsuppression, as did 60% after 2 weeks. While the level of depressive symptoms was initially high (HRSD score greater than 20) for 48% of the 27 patients interviewed within 2 weeks of abstinence, depressive symptoms cleared within 2 weeks in half of these cases. There were no associations between DST results and the presence of DSM-III major depressive disorder (lifetime or current) as assessed by the NIMH DIS, scores on the HRSD, or the presence of liver disease (elevated admission SGOT or SGPT). By the 15th-day of abstinence an examination of the clinical course of depressive symptoms differentiated those patients with a persistent major depressive episode from those with transient, alcohol-related depressive symptoms. An early positive DST had a positive predictive value of 20% for a clinical diagnosis of a major depressive episode, and a negative predictive value of 73%. After 2 weeks the positive and negative predictive values were each 50%.

The effect of acute alcohol withdrawal on the serum potassium and total body potassium in heavy drinkers.

In a group of 20 patients with heavy alcohol intake a relation was found between withdrawal symptoms and fall in serum potassium. Total body potassium (TBK) was measured in all subjects and was lower in the group of subjects who displayed symptoms than in the group who did not. The subgroup of the four most severe reactors had a mean TBK value significantly less than the 'non-reactor' group. The minimum serum potassium levels observed for all subjects in the four day period following alcohol withdrawal correlated with their TBK values. We suggest that the mechanism for the serum potassium fall might be overactivity of the Na-K pump caused by ethanol consumption. There was also an association between withdrawal reaction and abnormal liver function and a transient rise in serum phosphate in the more severely reacting subjects.