Contributor: Dillon Warr, MD
Pharmacist Reviewer: Elizabeth Tencza, PharmD BCCCP
Raise a glass to the GRACE-4 guidelines. These are Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE). The goal of GRACE is to focus on conditions for which there is wide variation in treatment, for which ED-focused clinical practice guidelines do not already exist, and for which patients have frequent ED revisits.�
The GRACE initiative has already covered low-risk, recurrent chest pain, low risk, recurrent abdominal pain, and acute dizziness and vertigo. Now, in GRACE-4they have published guidelines to help guide us on alcohol use disorder, alcohol withdrawal syndrome, and cannabis hyperemesis management in the ED.�
In this episode, we review their recommendations and try to offer some practical tips that you can take with you on your next shift.
- GRACE-4 writing team is a diverse collection of addiction medicine specialists, emergency medicine physicians with advanced training in addiction, GRADE methodologists, and patient representatives with lived experience related to AUD and CHS.�
- The use of patient representatives has been a common theme in the GRACE initiative and provides an invaluable perspective.
- Recommendations were based on 3 distinct PICO questions. Each question had extensive literature review and evidence synthesis that dictated their assessment of the quality of the evidence and the strength of their recommends
- PICO 1:In patients 18 years of age or older receiving pharmacologic therapy for moderate to severe alcohol withdrawal in the ED, does the use of adjunctive phenobarbital by any route compared to benzodiazepines alone lead to improvement in outcomes?
PICO 2: In patients 18 years of age or older who present to the ED with AUD who are discharged home, does the prescription of an anti-craving medication, compared to no prescription, improve outcomes?
PICO 3:In patients 18 years of age or older who present to the ED and are suspected to have CHS, does the use of dopamine antag- onists (e.g., haloperidol, droperidol) or capsaicin compared to usual care (or no treatment) lead to improved outcomes? The use of patient representatives has been a common theme in the GRACE initiative and provides an invaluable perspective. - Recommendations were based on 3 distinct PICO questions. Each question had extensive literature review and evidence synthesis that dictated their assessment of the quality of the evidence and the strength of their recommends
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