Alcohol Withdrawal Delirium or Benzodiazepine Intoxication Delirium or What?

It’s a common quandary. A patient comes in to hospital and denies recent use of alcohol but a relative might say he’s been drinking
heavily for decades.  Or he may say that
he’s been drinking heavily and has a history of delirium tremens and seizures
when withdrawing from alcohol in the past. The patient may be admitted to the
trauma service after an accident or to a general medical unit for some other
reason.

Abruptly, he starts to act confused and tries to leave the hospital. He may be disoriented or hallucinating. Despite normal or near normal vital signs and little to no subjective symptoms of alcohol withdrawal, the physician assumes that alcohol withdrawal is the cause and immediately starts giving the patient benzodiazepines such as Librium or Ativan. The patient doesn’t improve and the confusion worsens. The physician’s response is to increase the dose of
benzodiazepine, sometimes to the point of a continuous intravenous infusion. The
patient must then be intubated and transferred to the intensive care unit to
protect his airway.

His agitation gets worse.  Every time an attempt is made to dial down the
benzodiazepine infusion rate, the patient becomes more combative as the heavy
sedation lifts. A vicious cycle ensues with alternating higher doses of
benzodiazepine, periodic attempts to taper the drug with worse agitation
followed by putting the patient back to sleep with more benzodiazepine
sometimes adding other agents such as anesthetics. At that point a psychiatric
consultant is called. Depending on the level of experience the psychiatrist has
with withdrawal syndromes and with the management of delirium in general, the
recommendation may be to add another benzodiazepine, perhaps with one or more
antipsychotics.

Finally, the decision must be made to simply sharply limit
the doses of sedatives or even stop them and weather the combativeness as
safely as possible while the patient awakens. In the aftermath, after careful
review of the objective vital sign records and checking for other medical
causes of delirium—the conclusion is that alcohol withdrawal was not the cause
of the delirium. In fact, in retrospect the conclusion may also be that
well-intentioned aggressive efforts to treat presumed alcohol withdrawal with
sedatives actually caused or worsened delirium.

Scenarios similar to this are played out in hospitals
everywhere and speak to the critical importance of being alert for other
possible medical causes of delirium in patients with alcohol use disorders. Not
every patient (or relative, friend, spouse, acquaintance of the patient, etc.)
who gives a history of complicated alcohol withdrawal (alcohol withdrawal
seizures or delirium tremens) is a reliable reporter. And not every patient who
has a genuine history of complicated alcohol withdrawal will have the syndrome
each and every time he comes to hospital requesting detoxification.

There is a need for reliance on measurable objective signs
such as elevated blood pressure and heart rate, observable sweating, and visible
tremors in addition to subjective reports of distress in the diagnosis of
alcohol withdrawal.  Inappropriate use of
alcohol withdrawal assessment scales such as the Clinical Institute Withdrawal
Assessment-Revised (CIWA-Ar) in some hospital settings can lead to misdiagnosis
of alcohol withdrawal and adverse outcomes [1, 2].

It may be helpful to screen patients admitted to hospital
using validated scales such as the AUDIT-C though not all potential cases can
be captured in this way. The AUDIT-C is a 3-item alcohol screen that can help
identify patients who are hazardous drinkers or who have active alcohol use
disorders including alcohol abuse or dependence.

Using an alcohol withdrawal rating scale that emphasizes
objective signs of withdrawal could be another way to more reliably identify
those who are in withdrawal. And either symptom-triggered or fixed dose, scheduled
benzodiazepine tapers should be considered for those requiring medically
supervised detoxification in the hospital.

Finally—think about delirium from other medical causes in
patients who have alcohol use disorders. Many of these patients have a variety
of other medical problems that put them at risk for delirium.

1.            Bostwick, J.M. and M.I. Lapid, False positives on the clinical institute
withdrawal assessment for alcohol-revised: is this scale appropriate for use in
the medically ill?
Psychosomatics, 2004. 45(3): p. 256-61.

2.            Hecksel, K.A., et al., Inappropriate use of symptom-triggered therapy for alcohol withdrawal in the general hospital. Mayo Clin Proc, 2008. 83(3): p. 274-9.

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Comments

  1. Should we be using (other) anti-epileptic drugs, like perhaps gabapentin, instead of benzos for potential alcohol withdrawal?

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    • Hi again Moviedoc,

      Benzodiazepines are the treatment of choice for alcohol withdrawal. An abstract about a Cochrane Database review regarding anticonvulsants doesn’t bode well for Gabapentin:

      Anticonvulsants for alcohol withdrawal.

      Minozzi S, Amato L, Vecchi S, Davoli M.

      Source

      Department of Epidemiology, ASL RM/E, Via di Santa Costanza, 53, Rome, Italy, 00198.

      Abstract

      BACKGROUND:

      Alcohol abuse and dependence represents a most serious health problem worldwide with major social, interpersonal and legal interpolations. Besides benzodiazepines, anticonvulsants are often used for the treatment of alcohol withdrawal symptoms. Anticonvulsants drugs are indicated for the treatment of alcohol withdrawal syndrome, alone or in combination with benzodiazepine treatments. In spite of the wide use, the exact role of the anticonvulsants for the treatment of alcohol withdrawal has not yet been adequately assessed.

      OBJECTIVES:

      To evaluate the effectiveness and safety of anticonvulsants in the treatment of alcohol withdrawal.

      SEARCH STRATEGY:

      We searched Cochrane Drugs and Alcohol Group’ Register of Trials (December 2009), PubMed, EMBASE, CINAHL (1966 to December 2009), EconLIT (1969 to December 2009). Parallel searches on web sites of health technology assessment and related agencies, and their databases.

      SELECTION CRITERIA:

      Randomized controlled trials (RCTs) examining the effectiveness, safety and overall risk-benefit of anticonvulsants in comparison with a placebo or other pharmacological treatment. All patients were included regardless of age, gender, nationality, and outpatient or inpatient therapy.

      DATA COLLECTION AND ANALYSIS:

      Two authors independently screened and extracted data from studies.

      MAIN RESULTS:

      Fifty-six studies, with a total of 4076 participants, met the inclusion criteria. Comparing anticonvulsants with placebo, no statistically significant differences for the six outcomes considered.Comparing anticonvulsant versus other drug, 19 outcomes considered, results favour anticonvulsants only in the comparison carbamazepine versus benzodiazepine (oxazepam and lorazepam) for alcohol withdrawal symptoms (CIWA-Ar score): 3 studies, 262 participants, MD -1.04 (-1.89 to -0.20), none of the other comparisons reached statistical significance.Comparing different anticonvulsants no statistically significant differences in the two outcomes considered.Comparing anticonvulsants plus other drugs versus other drugs (3 outcomes considered), results from one study, 72 participants, favour paraldehyde plus chloral hydrate versus chlordiazepoxide, for the severe-life threatening side effects, RR 0.12 (0.03 to 0.44).

      AUTHORS’ CONCLUSIONS:

      Results of this review do not provide sufficient evidence in favour of anticonvulsants for the treatment of AWS. There are some suggestions that carbamazepine may actually be more effective in treating some aspects of alcohol withdrawal when compared to benzodiazepines, the current first-line regimen for alcohol withdrawal syndrome. Anticonvulsants seem to have limited side effects, although adverse effects are not rigorously reported in the analysed trials.

      Their bottom line?

      “Plain language summary

      Anticonvulsants for alcohol withdrawal syndrome
      There are limited data on anticonvulsants versus placebo for alcohol withdrawal syndrome, while comparisons with other drugs show no clear differences.

      This Cochrane review summarizes evidence from forty-eight randomised controlled trials evaluating the effectiveness and safety of anticonvulsants in the treatment of alcohol withdrawal symptoms. There are limited data comparing anticonvulsants versus placebo and no clear differences between anticonvulsants and other drugs in the rates of therapeutic success. Data on safety outcomes are sparse and fragmented. There is a need for larger, well-designed studies in this field.”

      Editorial group: Cochrane Drugs and Alcohol Group.
      Publication status and date: New search for studies and content updated (conclusions changed), published in Issue 3, 2010.
      Review content assessed as up-to-date: 29 December 2009.

      Citation: Minozzi S, Amato L, Vecchi S, Davoli M. Anticonvulsants for alcohol withdrawal. Cochrane Database of Systematic Reviews 2010, Issue 3. Art. No.: CD005064. DOI: 10.1002/14651858.CD005064.pub3.

      Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

      Best wishes,

      Jim Amos, MD

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