Undergraduate MBBS level Power Point presentation of Theory Class

1. ALCOHOLS
Dr. D. K. Brahma
Department of Pharmacology
NEIGRIHMS, SHILLONG

2. Why and What to Learn on
Alcohol ?
 The pharmacodynamics of alcohol actions in the body and
brain, that is the pharmacological effects that produce the
biological actions of the drug. (e.g. intoxication, organ
damage etc.)
 The pharmacokinetics of alcohol, that is the timing of alcohol
distribution and metabolism within the body and brain, as well
as the pathways involved in metabolism of ethanol and its
major metabolites.

3. What are they ?
 Ethyl Alcohol
(Ethanol)
Methyl Alcohol
(Methanol)

4. How Manufactured ?
• Fermentation – Sugar to Alcohol and Carbon
dioxide
C6H12O6→ 2(CH3-CH2-OH) + 2CO2
(Yeasts +sugar + water = CO2 + ethanol)
• Yeasts are living micro-organisms which die in
concentrations of alcohol greater than 10 to 15%
Starch Convertase
Maltose
• Commercially - obtained from Mollases

5. Alcoholic Beverages
 Malted Liquors: Fermentation of germinating cereals (malts) –
mostly Barley – Beers (3-6%)
 Wines: fermentation of Natural Sugars – grapes, apples and
other fruits
 No distillation, <15%
 Fortified (port) – up to 22%
 Champagne – 12-16% (effervescent wine)
 Spirits – Rum, Whisky, Brandy and Gin
 40 - 55% v/v
 Standard 42.8% v/v or 37% w/w
 Sources:
 Whiskey - distilled grain
 Rum - distilled molasses
 Gin – any sugar source
 Brandy – Distilled wine (Grapes)
 Vodka – fermentation of any of grain, rye, wheat, potatoes, grapes, sugar beet or mollases

6. Alcohol – Percentage Calculations
 Alcohol content of beverages:
 specific gravity of alcohol is 79
 Therefore, 1 litre alcohol weighs 790g
 Percent may be by weight or by volume
 By volume:
 1 litre alcohol add 1 litre water = 50% (vol)
 By weight:
 1 litre alcohol (790g), add 790g water = 50%
(weight)
40% alcohol by weight = 50% by volume

7. 1litre water
+ =
1litre alcohol
2 litres 50% (volume)
1 kilo water 1 kilo alcohol
2 kilos 50% (weight)
+ =
40% alcohol by weight = 50% by volume

8. Pharmacological actions of
alcohol - Local
1. Rubefacient and counterirritant to skin
2. Irritant – soft skin and mucus
membrane
3. Pain, inflammation and necrosis –
injection
4. Astringent: Antiseptic (20 – 90%)
 100% is dehydrating
1. No action on spores

9. Effects of alcohol consumption -
Acute
 CNS:
 depressant – dose dependent manner
Plasma concentration Expected effects
30 – 100 mg/dl Anxiolytic, euphoria and excitation
Hesitation, restraint, caution are lost
Impaired coordination – mood and feelings are
altered
100 -150 mg/dl Mental clouding, ataxia, disorganization of thought
and impairment of memory and drowsiness
150 – 200 mg/dl Sloppy, ataxia and drunkenness
- Slurring of speech, loss of judgment and inhibition
200 – 300 mg/dl Stupor and unconsciousness

10. Effects of alcohol consumption
(acute) - contd.
 Impaired performance, slowing of reflexes and
fine discrimination impaired
 Induces sleep – but not ideal hypnotic
 Analgesic – but no ideal analgesic
 Anticonvulsant action – but not ideal
anticonvulsant
 Mechanism:
 GABAA receptor mediated synaptic inhibition by
chloride channel opening
 Inhibition of NMDA excitatory amino acid receptor
 Stimulates 5-HT3 receptors

11. Effects of alcohol consumption
(acute) - contd.
 CVS:
 Small doses – cutaneous vasodilatation, flushing
 Medium dose – tachycardia and mild rise in BP
 Large dose - Vasodilatation due to direct vascular
smooth muscle dilatation and vasomotor centre
depression (clinical implication)
 Respiration:
 Stimulation of Respiration – by irritation of
pharyngeal and buccal mucosa
 Central action – depression
 Blood:
 Moderate drinking increases HDL-cholesterol
level
 Decrease in LDL oxidation

12. Effects of alcohol consumption
(acute) - contd.
 GIT:
 Dilute alcohol at low
doses - stimulate GI
secretion – flavour,
aroma or direct
action on gastrin
secretion
 Higher doses inhibit
GI secretion
 Acute consumption
– pylorospasm,
gastritis, vomiting,
reflux etc
 Mallory-Weiss lesion

13. Effects of alcohol consumption –
(acute) - contd.
 Kidney: Diuresis – increased water
ingestion and inhibition of ADH
 Uterus: Relaxation of uterine muscles
 Endocrine:
 Low dose – Adrenaline release and
hyperglycemia
High dose – Hypoglycemia
 Sex - Aphrodisiac

14. Absorption
 Rapidly absorbed from small intestine,
and colon but slowly from stomach
 First pass metabolism in stomach and
liver
 Maximal blood concentration within 30 to
90 minutes
 Can be absorbed through the lungs
 Can be absorbed through skin

15. Distribution
 Uniformly distributed throughout tissues and body
fluids
 Readily crosses placenta, to exposure fetus
 Crosses BBB readily
Elimination
Urinary Excretion
Exhalation
Metabolism

16. Metabolism I
H
H
H C OH
H
C
H
Ethanol
H
H C
H
=
C O
H
Acetaldehyde
ADH
(ADH – Alcohol Dehydrogenase)

17. Metabolism II
H
H C
H
=
C O
H
ALDH
H
H C
H
=
C O
OH
Acetaldehyde
Acetate
(ALDH – Acetaldehyde Dehydrogenase)

18. Metabolism III
 80-90% Metabolized
 Also metabolized in small amounts by hepatic
microsomal enzyme
 Rate is constant (not increased by
concentrations in the blood) – zero order (8-12
ml/H of absolute alcohol)
 About 30 ml (1 oz) in 3 hours
 Concentration in exhaled air is 0.05% of blood
concentration – used in medico legal purposes

19. Adverse Effects of Alcohol
 Acute Effects
 Nausea, Vomiting, hangover and traffic accidents
 CNS Depressant
 Depression of inhibitory control
 Vasodilatation, warm, flushed, reddish skin
 Emotional outbursts
 Decreased memory & concentration
 Poor judgment
 Decreased reflexes
 Decreased sexual response

20. Adverse Effects of Alcohol –
contd.
 Acute Alcohol Intoxication:
 Estimated ED50: 150 mg/100 ml and LD50 = 500
mg/100ml
 Therapeutic index about 3.5
 Hypotension, hypoglycemia, respiratory depression
coma and death
 Death due to respiratory depression or inhaled vomit
 Treatment:
 Gastric lavage
 Endotracheal intubations
 Fluid and electrolyte balance
 Glucose infusion
 Thiamine injection 100 mg in 500 ml of glucose IV
 Haemodialysis

21. Consequences of acute
Alcohol intoxication - images
Vomiting Driving accidents Loss of inhibitions
Hangover

22. Toxic Effects - Chronic
Alcoholism
 GIT:
 Gastritis and damage to the mucosa –
anaemia
 Intestinal damage: Lack of absorption -
Deficiency of water soluble vitamins and
amino acids (protein deficiency)
 Less or no food intake (enough calorie) -
Vitamin and Protein deficiency
(Q. Is Alcohol a total food ? Answer: No -
Lacking in total food value)

23. Chronic Alcoholism – contd.
 Liver cirrhosis – scarring of
liver
 Usually fatal if drinking
is not stopped
 Fatty infiltration
(excess in NADH)
 Oxidative stress and
cellular necrosis
 Damage to
hepatocytes and
inflammation –
aldehyde
 Glutathione
depletion
 Microsomal enzyme
induction

24. Chronic Alcoholism – contd.
 Neurological: Polyneuritis, pellagra,
tremors, seizures, loss of brain mass,
Korsakoff`s psychosis and Warnicke`s
encephalopathy
 CVS: Hypertension, cardiomyopathy,
CHF arrhythmias and stroke
 Hormonal: Impotence, gynaecomastia
and infertility
 Acute pancreatitis

25. Chronic Alcoholism – contd.
 Reproduction
 Alcohol is a teratogen, it causes birth
defects.
 Fetal Alcohol Syndrome (FAS) or Fetal
Alcohol Effects (FAE), or Alcohol-Related
Birth Defects (ARBD)
 Symptoms include retardation, poor
coordination, loss of muscle tone, low birth
weight, slow growth, malformation of internal
organs and peculiar facial characteristics

26. Fetal Alcohol Syndrome (FAS)
Characteristics
Growth retardation
Facial malformations
Small head
Greatly reduce
intelligence

27. Chronic Alcoholism - features
• Craving: A strong need, or compulsion, to drink
• Loss of control: The inability to limit one’s drinking on any given
occasion
• Tolerance: The need to drink greater amounts of alcohol in order to
“get high” – pharmacokinetic or cellular tolerance
• Physical dependence: Withdrawal symptoms, such as nausea,
sweating, shakiness, sleep impairment, hallucinations, delirium
tremens and anxiety, occur when alcohol use is stopped after a
period of heavy drinking
• Withdrawal syndromes: long acting BZDs like chlordizepoxide
and diazepam
• Naltrexone (50 mg)

28. Ethanol – Usefulness:
1. Local:
 antiseptic, rubefacient and counterirritant in sparins
and to prevent bedsores
 antiperspirant and aftershave
 Alcohol sponges – to reduce body temperature
1. Appetite stimulant and carminative: 30 – 60 ml of 7-
10%
2. Neuralgias: severe cancer pain – injection round the
nerve
3. Protection from cold
4. Alcohol may have a protective effect from heart attack
and stroke - frugivores
5. Methanol Poisoning

29. Disulfiram (Antabuse)
 Internationally marketed as antabuse
 ALDH enzyme inhibitor
 Alcohol + disulfiram rise in concentration of aldehyde in
blood and tissue distressing aldehyde syndrome
 Symptoms: flushing, burning sensation, throbbing headache,
perspiration, dizziness, vomiting, visual disturbance, mental
confusion, fainting and circulatory collapse
 Uses: aversion technique in chronic alcoholics: only to
motivated persons
 Technique: abstain alcohol overnight and start with 1 gm on
day 1 followed by 0.75 gm next day and 0.50 gm next day and
so on. Effects start within few hrs of 1st dose and lasts for 2
weeks
 Mechanism: irreversible inhibition of ALDH and synthesis of
new enzyme takes time and thus person resolves not to drink
for distressing symptoms
 Available as 250 mg tablets

30. Ethanol as Antidote
 Methanol, Ethylene glycol, Diethylene glycol
 Methanol poisoning – toxicological importance –
unscrupulous mixing with alcoholic beverages
 Formic acid is toxic: above 50 mg/dl, lethal dose 75 – 100
ml, even 15 ml can cause blindness
ADH ALDH
Methanol formaldehyde Formic acid
 Methanol poisoning: vomiting, epigastric pain dyspnoea,
bradycardia, acidosis – permanent retinal damage and
Death
 Mechanism: Ethanol saturates alcohol dehydrogenase
enzyme - no metabolism of Methanol to form Formic acid

31. Methanol Poisoning
treatment
 Patient in dark room, Ventilation and BP supportive measures
 Gastric lavage with sodibicarb if brought immediately
 IV sodibicarb to combat acidosis – large quantity may be
required
 Ethanol 10% in water – nasogastric tube with loading dose of
0.7 ml/kg followed by 15 ml/kg/hr by infusion – continue
treatment for several days (methanol is oxidized slowly)
 Potassium chloride if hypokalemia occurs
 Folinic acid or Calcium leucovorin ijection 50 mg IV every 6 Hrly
– to enhance oxidation of formic acid
 4-methylpyrazole – specific inhibitor of ALD – 15 mg/kg IV and
10 mg/kg 12 Hrly. till methanol level is <20 mg/dl
 Haemodialysis

32. Summary
 Alcohol is a neuronal depressant
 Long term exposure to alcohol brings about
adaptive changes in the neuronal system
 Chronic alcoholism causes toxic effects on all
the organs especially liver
 Withdrawal syndrome in alcoholics are treated
by BZDs and Naltrexone
 Antbuse/disulfiram is the drug is use as
aversion technique in chronic alcoholics
 Ethanol is used as antidote in Methanol
Poisoning

33. Thank You