The Geezer’s Dirty Dozen on Treatment of Alcohol Withdrawal

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This is another Dirty Dozen and it’s about managing alcohol withdrawal. I’ve included links to my other blog posts about this topic. An excerpt from Chapter 21 on alcohol withdrawal management in Psychosomatic Medicine: An Introduction to Consultation-Liaison Psychiatry (a book edited by myself and Dr. Robert G. Robinson):

Because of toxicity concerns, the use of intravenous or oral ethyl alcohol is discouraged. In general, agents with longer elimination half-lives are preferred because they may be more effective in preventing seizures and may contribute to a smoother alcohol withdrawal. Conversely, shorter-acting benzodiazepines may cause less over-sedation and may be safer in the elderly or in patients with severe liver disease.

Symptom-triggered treatment of alcohol withdrawal using assessment scales such as the CIWA-Ar is the preferred method. A score of less than ten indicates the need for continued monitoring of the patient. A score of 10 to 15 indicates mild withdrawal, 16 to 20 moderate withdrawal, and greater than 20 severe withdrawal…After the 24-hour dosage is determined, a detox schedule can be devised by tapering the overall dosage by 20% per day. All patients being treated for alcohol withdrawal should also immediately receive thiamine 100 mg IM/IV for three days to prevent the Wernicke-Korsakoff syndrome, plus folate 1 mg daily.

Slide 3: This a slide with a few basic facts about alcohol use disorders.

Slide 4: This slide defines alcohol withdrawal and mentions a couple of withdrawal strategies about phenobarbital and baclofen that might deserve further study but which cannot be recommended for standard protocols yet.

Slide 5: One of the most important questions to ask the patient or family member is when was the patient’s last drink.

Slide 6: This slide just lists the signs and symptoms of alcohol withdrawal.

Slide 7: These are the estimates of the time to onset of certain signs and symptoms of alcohol withdrawal.

Slide 8: There are pros and cons to standardized protocols for managing alcohol withdrawal, specifically as they relate to symptom-triggered protocols. Symptom-triggered protocols generally use less benzodiazepine, but unless you can communicate with the patient, you can end up harming him or her by using it in the first place. See Heckels et al, 2008 in the reference slide. Benzodiazepines are the treatment of choice and as a general rule, drugs like Lorazepam and Oxazepam are used in the elderly and those with liver failure while Chlordiazepoxide is used in generally healthier adult alcoholics.  What is not explicitly covered in this slide set is the need to be vigilant about providing thiamine supplementation as many alcoholics tend to be deficient in this vitamin. See the Thomson et al reference for further details.

Slide 9: Symptom-triggered protocols require staff training in the use of validated alcohol symptom withdrawal rating scales such as the CIWA-Ar shown in the next slide.

Slide 10: The Clinical Institute for Withdrawal (CIWA-Ar) scale, a commonly used tool although there are others which are sometimes made by the institution running a study on symptom-triggered protocols. An example is the Glasgow Modified Alcohol Withdrawal Scale (GMAWS) used in the McPherson et al study (see reference).

Slide11: This is the usual slide of references for this Dirty Dozen.

Slide 12: This is a slide with a list of my blog posts on the topic of alcohol withdrawal treatment:

Bialer, P. A. and A. C. Miller (2010). Management of alcohol withdrawal and other selected substance withdrawal issues. Psychosomatic Medicine: An Introduction to Consultation-Liaison Psychiatry. J. J. Amos, M.D. and R. G. Robinson, M.D. New York, Cambridge University Press: 193-201.

Cassidy, E. M., I. O’Sullivan, et al. (2011). “Symptom-triggered benzodiazepine therapy for alcohol withdrawal syndrome in the emergency department: a comparison with the standard fixed dose benzodiazepine regimen.” Emergency Medicine Journal.

The aim of the study was to compare symptom-triggered and standard benzodiazepine regimens for the treatment of alcohol withdrawal syndrome in an emergency department clinical decision unit. The authors found that the symptom-triggered approach reduced cumulative benzodiazepine dose and length of stay.

Daeppen, J.-B., P. Gache, et al. (2002). “Symptom-Triggered vs Fixed-Schedule Doses of Benzodiazepine for Alcohol Withdrawal: A Randomized Treatment Trial.” Arch Intern Med 162(10): 1117-1121.

Background In alcohol withdrawal, fixed doses of benzodiazepine are generally recommended as a first-line pharmacologic approach. This study determines the benefits of an individualized treatment regimen on the quantity of benzodiazepine administered and the duration of its use during alcohol withdrawal treatment. Methods We conducted a prospective, randomized, double-blind, controlled trial including 117 consecutive patients with alcohol dependence, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, entering an alcohol treatment program at both the Lausanne and Geneva university hospitals, Switzerland. Patients were randomized into 2 groups: (1) 56 were treated with oxazepam in response to the development of signs of alcohol withdrawal (symptom-triggered); and (2) 61 were treated with oxazepam every 6 hours with additional doses as needed (fixed-schedule). The administration of oxazepam in group 1 and additional oxazepam in group 2 was determined using a standardized measure of alcohol withdrawal. The main outcome measures were the total amount and duration of treatment with oxazepam, the incidence of complications, and the comfort level. Results A total of 22 patients (39%) in the symptom-triggered group were treated with oxazepam vs 100% in the fixed-schedule group (P<.001). The mean oxazepam dose administered in the symptom-triggered group was 37.5 mg compared with 231.4 mg in the fixed-schedule group (P<.001). The mean duration of oxazepam treatment was 20.0 hours in the symptom-triggered group vs 62.7 hours in the fixed-schedule group (P<.001). Withdrawal complications were limited to a single episode of seizures in the symptom-triggered group. There were no differences in the measures of comfort between the 2 groups. Conclusions Symptom-triggered benzodiazepine treatment for alcohol withdrawal is safe, comfortable, and associated with a decrease in the quantity of medication and duration of treatment.

Elholm, B., K. Larsen, et al. (2011). “Alcohol Withdrawal Syndrome: Symptom-Triggered versus Fixed-Schedule Treatment in an Outpatient Setting.” Alcohol and Alcoholism 46(3): 318-323.

Aims: To investigate whether, in the treatment with chlordiazepoxide for outpatient alcohol withdrawal, there are advantages of symptom-triggered self-medication over a fixed-schedule regimen. Methods: A randomized controlled trial in outpatient clinics for people suffering from alcohol dependence (AD) and alcohol-related problems; 165 adult patients in an outpatient setting in a specialized alcohol treatment unit were randomized 1:1 to either a symptom-triggered self-medication or tapered dose, using chlordiazepoxide. Alcohol withdrawal symptoms, amount of medication, duration of symptoms, time to relapse and patient satisfaction were measured. Patients assessed their symptoms using the Short Alcohol Withdrawal Scale (SAWS). Patient satisfaction was monitored by the Diabetes Treatment Satisfaction Questionnaire. We used the Well-Being Index and the European addiction severity index for the 1-year follow-up. Results: We found no differences in the quantity of medication consumed, time to relapse, well being or treatment satisfaction. Conclusion: Symptom-triggered self-medication was as safe as fixed-schedule medication in treating outpatients with AD and mild to moderate symptoms of AWS. The SAWS is a powerful monitoring tool, because it is brief and permits the subject to log the withdrawal symptoms.

Finn, K. M. and J. Greenwald (2011). “Hospitalists and alcohol withdrawal: Yes, give benzodiazepines but is that the whole story?” Journal of Hospital Medicine 6(8): 435-437.

Hecksel, K. A., J. M. Bostwick, et al. (2008). “Inappropriate Use of Symptom-Triggered Therapy for Alcohol Withdrawal in the General Hospital.” Mayo Clinic Proceedings 83(3): 274-279.

OBJECTIVE: To determine if hospitalized medical and surgical patients were placed Inappropriately on symptom-triggered therapy (STT) for alcohol withdrawal syndrome (AWS) and If certain conditions were more likely to be associated with inappropriate STT use or adverse events. PATIENTS AND METHODS: We randomly selected 124(25%) of the 495 Mayo Clinic inpatients who received STT according to the Revised Clinical Institute for Withdrawal Assessment for Alcohol (CIWA-Ar) protocol In 2003 and assessed them for Sir appropriateness, defined as having both intact verbal communication and recent alcohol use. Adverse events, including delirium tremens, seizures, or death, were correlated with CIWA-Ar appropriateness. RESULTS: Of the 124 randomly selected patients, only 60 (48%) met both Inclusion criteria. Of the remaining 64 patients, 9 (14%) were drinkers but could not communicate, and 35 (55%) could communicate but had not been drinking. Twenty (31%) met neither criterion. Univariate analysis identified a significant association between inappropriate initiation and chronic heart failure, postoperative status (POS), liver disease (LD), nonmetastatic cancer, and chemical dependency consultation. On multivariate analysis, only LD (P=.02) and POS (P=.01) retained significance, with LD more and POS less likely to predict appropriateness. Seven of 11 patients who experienced adverse events had received STT according to the CIWA-Ar protocol (P=.05). Univariate analysis Identified a significant association between adverse events and a history of alcohol dependence or AWS. Multivariate analysis showed significance only for a history of alcohol dependence (P=.049). CONCLUSION: Fewer than half of the randomly selected patients met both of the inclusion criteria for the CIWA-Ar instrument, leading us to conclude that more stringent evaluation is needed. Particularly postoperatively, alternative explanations for putative AWS should be sought. Health care professionals should more aggressively seek Information on recent alcohol use from medical records, family members, and patients themselves. [ABSTRACT FROM AUTHOR]

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Hillbom, M., I. Pieninkeroinen, et al. (2003). “Seizures in alcohol-dependent patients: epidemiology, pathophysiology and management.” CNS Drugs 17(14): 1013-1030.

The relationship between alcohol and seizures is complex and multifaceted. The prevalence of epilepsy in alcohol-dependent patients of western industrialised countries may be at least triple that in the general population, whereas the prevalence of alcoholism is only slightly higher in patients with epilepsy than in the general population. The seizure threshold is raised by alcohol drinking and declines on cessation of drinking. As a result, during withdrawal from alcohol, usually 6-48 hours after the cessation of drinking, seizures may occur. Alcohol acts on the brain through several mechanisms that influence seizure threshold. These include effects on calcium and chloride flux through the ion-gated glutamate NMDA and GABA receptors. During prolonged intoxication, the CNS adapts to the effects of alcohol, resulting in tolerance; however, these adaptive effects seem to be transient, disappearing after alcohol intake is stopped. Although the relationship of seizures to alcohol use is likely to be dose dependent and causal, the available clinical data do not suggest that alcohol use results in seizure genesis. However, a genetic predisposition to alcohol withdrawal seizures is possible. Other seizures in alcohol-dependent individuals may be due to concurrent metabolic, toxic, infectious, traumatic, neoplastic and cerebrovascular diseases and are frequently partial-onset seizures. Alcohol abuse is a major precipitant of status epilepticus (9-25% of cases), which may even be the first-ever seizure type. Prompt treatment of alcohol withdrawal seizures is recommended to prevent status epilepticus. During the detoxification process, primary and secondary preventative measures can be taken. A meta-analysis of controlled trials for the primary prevention of alcohol withdrawal seizures demonstrated a highly significant risk reduction for seizures with benzodiazepines and antiepileptic drugs and an increased risk with antipsychotics. A meta-analysis of randomised, placebo-controlled trials for the secondary prevention of seizures after alcohol withdrawal showed lorazepam to be effective, whereas phenytoin was ineffective. Because withdrawal seizures do not recur if the patient remains abstinent, long-term administration of antiepileptic drugs is unnecessary in abstinent patients. The first seizure not related to alcohol withdrawal should not result in permanent drug treatment in an alcohol-dependent patient, because of poor compliance and the high likelihood of remission. The treatment of alcohol dependence is more important and should be prioritised before the prevention of further seizures.

Lansford, C. D., C. H. Guerriero, et al. (2008). “Improved Outcomes in Patients With Head and Neck Cancer Using a Standardized Care Protocol for Postoperative Alcohol Withdrawal.” Arch Otolaryngol Head Neck Surg 134(8): 865-872.

Objective To show clinical benefit in the main outcome measures by the use of a standardized protocol for identification, characterization, and treatment of alcohol withdrawal syndrome (AWS) in postoperative patients with head and neck cancer. Design Prospective cohort study with a retrospective cohort control. Setting Tertiary care university. Patients A total of 26 consecutive postoperative patients with AWS were selected from among 652 patients with head and neck cancer to be enrolled in the protocol from March 2003 through March 2005. Controls consisted of 14 of 981 consecutive patients with AWS from March 2000 through December 2002. Intervention Application of a standardized care protocol. Main Outcome Measures Sensitivity and specificity of preoperative screening for AWS risk, predictability of outcomes, length of stay, transfers to the intensive care unit (ICU), AWS symptoms, postoperative morbidity and mortality, doses of pharmacotherapy required, and charges. Results Protocol patients demonstrated significantly fewer AWS-related ICU transfers and less delirium and violence than preprotocol patients. Mortality, wound complications, hospital charges, and doses of benzodiazepines, clonidine, and haloperidol were not significantly different between these 2 groups. Preoperative medical history correlated poorly with AWS outcomes. Screening was 87.5% sensitive and 99.7% specific. Late enrollees to the protocol (false-negative screening results) showed many significantly worse outcomes than immediate enrollees. Conclusion Use of the standardized AWS symptom-triggered protocol decreased delirium, violence, and AWS-related ICU transfers without significantly increasing hospital charges.

Mayo-Smith, M. F. (1997). “Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal.” JAMA : the journal of the American Medical Association 278(2): 144-151.

OBJECTIVE: To provide an evidence-based practice guideline on the pharmacological management of alcohol withdrawal. DATA SOURCES: English-language articles published before July 1, 1995, identified through MEDLINE search on “substance withdrawal–ethyl alcohol” and review of references from identified articles. STUDY SELECTION: Articles with original data on human subjects. DATA ABSTRACTION: Structured review to determine study design, sample size, interventions used, and outcomes of withdrawal severity, delirium, seizures, completion of withdrawal, entry into rehabilitation, adverse effects, and costs. Data from prospective controlled trials with methodologically sound end points corresponding to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, were abstracted by 2 independent reviewers and underwent meta-analysis. DATA SYNTHESIS: Benzodiazepines reduce withdrawal severity, reduce incidence of delirium (-4.9 cases per 100 patients; 95% confidence interval, -9.0 to -0.7; P=.04), and reduce seizures (-7.7 seizures per 100 patients; 95% confidence interval, -12.0 to -3.5; P=.003). Individualizing therapy with withdrawal scales results in administration of significantly less medication and shorter treatment (P<.001). beta-Blockers, clonidine, and carbamazepine ameliorate withdrawal severity, but evidence is inadequate to determine their effect on delirium and seizures. Phenothiazines ameliorate withdrawal but are less effective than benzodiazepines in reducing delirium (P=.002) or seizures (P<.001). CONCLUSIONS: Benzodiazepines are suitable agents for alcohol withdrawal, with choice among different agents guided by duration of action, rapidity of onset, and cost. Dosage should be individualized, based on withdrawal severity measured by withdrawal scales, comorbid illness, and history of withdrawal seizures. beta-Blockers, clonidine, carbamazepine, and neuroleptics may be used as adjunctive therapy but are not recommended as monotherapy.

Mayo-Smith, M. F., L. H. Beecher, et al. (2004). “Management of alcohol withdrawal delirium. An evidence-based practice guideline.” Archives of internal medicine 164(13): 1405-1412.

BACKGROUND: Alcohol withdrawal delirium is the most serious manifestation of alcohol withdrawal. Evidence suggests that appropriate care improves mortality, but systematic reviews are unavailable. METHODS: Articles with original data on management of alcohol withdrawal delirium underwent structured review and meta-analysis. RESULTS: Meta-analysis of 9 prospective controlled trials demonstrated that sedative-hypnotic agents are more effective than neuroleptic agents in reducing duration of delirium and mortality, with a relative risk of death when using neuroleptic agents of 6.6. Statistically significant differences among various benzodiazepines and barbiturates were not found. No deaths were reported in 217 patients from trials using benzodiazepines or barbiturates. CONCLUSIONS: Control of agitation should be achieved using parenteral rapid-acting sedative-hypnotic agents that are cross-tolerant with alcohol. Adequate doses should be used to maintain light somnolence for the duration of delirium. Coupled with comprehensive supportive medical care, this approach is highly effective in preventing morbidity and mortality.

McGregor, C., A. Machin, et al. (2003). “In-patient benzodiazepine withdrawal: comparison of fixed and symptom-triggered taper methods.” Drug and Alcohol Review 22(2): 175-180.

Fixed and symptom-triggered taper methods during in-patient benzodiazepine withdrawal treatment were compared using a randomized controlled design. Forty-four benzodiazepine users seeking in-patient withdrawal treatment at two substance use treatment clinics in Adelaide, Australia were recruited. Measurements included the Severity of Dependence Scale and the SF–36. A scale comprising six items from the Clinical Institute Withdrawal Assessment Scale—Benzodiazepines (CIWA-B) was used to measure withdrawal symptoms. Participants were randomized to receive a fixed diazepam tapering regime or diazepam only in response to withdrawal symptoms (symptom-triggered group). Results showed that there were no significant differences between treatment groups in terms of withdrawal severity, duration of in-patient treatment, amount of diazepam administered, treatment attrition and benzodiazepine use at follow-up. Both groups showed a reduction in benzodiazepine dosage of 86% over the first 8 days which was maintained at 1 month post-discharge. Although there were improvements in some subscales of the SF–36 between baseline and follow-up, values were significantly below age-matched norms at both time-points. This study showed that benzodiazepine users entering treatment have relatively poor health and that symptom-triggered taper methods incorporating flexible dosing and flexible treatment duration are as effective as fixed dose taper methods for in-patient benzodiazepine withdrawal treatment.

McKeon, A., M. A. Frye, et al. (2008). “The alcohol withdrawal syndrome.” Journal of neurology, neurosurgery, and psychiatry 79(8): 854-862.

The alcohol withdrawal syndrome (AWS) is a common management problem in hospital practice for neurologists, psychiatrists and general physicians alike. Although some patients have mild symptoms and may even be managed in the outpatient setting, others have more severe symptoms or a history of adverse outcomes that requires close inpatient supervision and benzodiazepine therapy. Many patients with AWS have multiple management issues (withdrawal symptoms, delirium tremens, the Wernicke-Korsakoff syndrome, seizures, depression, polysubstance abuse, electrolyte disturbances and liver disease), which requires a coordinated, multidisciplinary approach. Although AWS may be complex, careful evaluation and available treatments should ensure safe detoxification for most patients.

McPherson, A., G. Benson, et al. (2012). “Appraisal of the Glasgow assessment and management of alcohol guideline: a comprehensive alcohol management protocol for use in general hospitals.” QJM.

Background: Guidelines exist for the management of alcohol withdrawal syndrome (AWS) but few have been assessed as to their suitability for general hospitals. The Glasgow Assessment and Management guideline for alcohol has been specifically developed for use in this context.Aim: To determine if this alcohol assessment guideline aids the management of AWS in general hospitals.Design: The four components of the Glasgow Assessment and Management of Alcohol guideline were evaluated. This included the use of the Fast Alcohol Screening Test (FAST) to identify at risk patients, a risk stratification strategy to indicate fixed dose or symptom-triggered benzodiazepine treatment, the Glasgow Modified Alcohol Withdrawal Scale (GMAWS) for symptom-triggered treatment and a clear recommendation for vitamin prophylaxis of Wernicke’s encephalopathy.Methods: FAST scores were assessed along with the CAGE (cut down, annoyed, guilty and eye-opener) screening tool to ascertain if a single screening tool could identify hazardous and dependent drinking. The GMAWS and Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) were compared between two medical units. A staff survey of the two AWS tools was also carried out.Results: FAST was able to identify both probable hazardous and dependent drinking. The GMAWS was reliable and gauged both physical and cognitive aspects of AWS. Staff generally preferred the GMAWS-based treatment as opposed to CIWA-Ar management and welcomed the Guideline as a whole.Conclusions: The Glasgow Guideline aids the management of patients with AWS in an acute hospital setting. It allows early identification of at risk patients and directs effective therapeutic intervention.

Rosenbaum, M. and T. McCarty (2002). “Alcohol prescription by surgeons in the prevention and treatment of delirium tremens: historic and current practice.” General Hospital Psychiatry 24(4): 257-259.

Beer, other alcohol beverages, and IV alcohol are still used to prevent or treat alcohol withdrawal delirium on surgical services. The history of the use of alcohol by surgeons may play a role in its continued use for withdrawal. In this policy survey 32 inpatient hospital pharmacies were called and asked if alcohol was available, if it was used to treat alcohol withdrawal, and the medical specialties that requested it. Recommendations about the use of alcohol were examined in recent textbooks and from those published early in the twentieth century. One half of the 32 hospitals surveyed had alcoholic beverages available for patient use and eleven hospitals used either package alcohol or IV alcohol in the treatment of alcohol withdrawal. Surgeons used alcohol before anesthesia to help patients tolerate procedures, and the use of alcohol for treatment of alcohol withdrawal still appears in the surgical literature. This preliminary survey indicates that some hospitals still provide beverage alcohol for the treatment of alcohol withdrawal and that surgeons are the specialty ordering alcohol for their patients.

Saitz, R., M. F. Mayo-Smith, et al. (1994). “Individualized Treatment for Alcohol Withdrawal.” JAMA: The Journal of the American Medical Association 272(7): 519-523.

Objective. —To assess the effect of an individualized treatment regimen on the intensity and duration of medication treatment for alcohol withdrawal.Design. —A randomized double-blind, controlled trial.Setting. —An inpatient detoxification unit in a Veterans Affairs medical center.Patients. —One hundred one patients admitted for the treatment of alcohol withdrawal who could give informed consent and had no history of seizures or medication use that might alter the clinical course of withdrawal.Intervention. —Patients were randomized to either a standard course of chlordiazepoxide four times daily with additional medication as needed (fixed-schedule therapy) or to a treatment regimen that provided chlordiazepoxide only in response to the development of the signs and symptoms of alcohol withdrawal (symptomtriggered therapy). The need for administration of “as-needed” medication was determined using a validated measure of the severity of alcohol withdrawal.Main Outcome Measures. —Duration of medication treatment and total chlordiazepoxide administered.Results. —The median duration of treatment in the symptom-triggered group was 9 hours compared with 68 hours in the fixed-schedule group (P<.001). The symptom-triggered group received 100 mg of chlordiazepoxide, and the fixed-schedule group received 425 mg (P<.001). There were no significant differences in the severity of withdrawal during treatment or in the incidence of seizures or delirium tremens.Conclusions. —Symptom-triggered therapy individualizes treatment, decreases both treatment duration and the amount of benzodiazepine used, and is as efficacious as standard fixed-schedule therapy for alcohol withdrawal.(JAMA. 1994;272:519-523)

Thomson, A. D., C. C. H. Cook, et al. (2002). “THE ROYAL COLLEGE OF PHYSICIANS REPORT ON ALCOHOL: GUIDELINES FOR MANAGING WERNICKE’S ENCEPHALOPATHY IN THE ACCIDENT AND EMERGENCY DEPARTMENT.” Alcohol and Alcoholism 37(6): 513-521.

The Royal College of Physicians (London) recently published its latest report on alcohol misuse entitled ‘Alcohol — Can the NHS Afford It?’. Part of this document, encompassing our views, has made specific recommendations for the management of patients in the Accident and Emergency (A&E) Department who may possibly have, or are at risk of developing, Wernicke’s encephalopathy. Patients showing evidence of chronic alcohol misuse and suspected of having a poor diet should be treated at the outset with B vitamins intravenously or intramuscularly, especially when the clinical signs are initially masked by drunkenness at presentation to the A&E Department. This commentary offers a review of the scientific foundations on which these recommendations have been made.

Weaver, M. F., H. J. Hoffman, et al. (2006). “Alcohol Withdrawal Pharmacotherapy for Inpatients with Medical Comorbidity.” Journal of Addictive Diseases 25(2): 17 – 24.

Studies show that symptom-triggered dosing is best for treatment of alcohol withdrawal in patients on chemical dependence wards without other illness. On general medical hospital wards, withdrawal may be affected by comorbid medical illness. A clinical trial was undertaken to determine whether there is a difference between symptom-triggered (ST) and fixed-schedule (FS) dosing of lorazepam in patients hospitalized on general medical wards at a university medical center. One hundred eighty-three subjects were assessed by their nurses with the Revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale. Subjects in the ST arm received lorazepam doses based on CIWA-Ar score. Subjects in the FS arm received scheduled lorazepam with tapering over 4 days. Symptom-triggered dosing for alcohol withdrawal for general medicine inpatients results in less lorazepam given with similar reduction in CIWA-Ar scores for the first 2 days, but a higher proportion of protocol errors.

Weinberg, J. A., L. J. Magnotti, et al. (2008). “Comparison of intravenous ethanol versus diazepam for alcohol withdrawal prophylaxis in the trauma ICU: results of a randomized trial.” The Journal of trauma 64(1): 99-104.

BACKGROUND: Although benzodiazepines are the recommended first-line therapy for the prevention of alcohol withdrawal syndrome (AWS), the administration of intravenous ethanol as an alternative prophylactic agent persists in many surgical ICUs. Advocates of this therapy argue that ethanol provides effective prophylaxis against AWS without the excessive sedation observed with benzodiazepine therapy. No study to date, however, has compared the two therapies with regard to their sedative effects. The purpose of this study was to prospectively evaluate the efficacy of intravenous ethanol compared with benzodiazepines for the prevention of AWS with particular emphasis on the sedative effects of each therapy. METHODS: During a 15-month period, trauma patients admitted to the ICU with a history of chronic daily alcohol consumption greater than or equal to five beverage equivalents per day were prospectively randomized to one of two 4-day prophylactic regimens: intravenous ethanol infusion (EtOH) versus scheduled-dose diazepam (BENZO). Patients were evaluated with the Riker sedation-agitation scale, a 7-point instrument for the subjective assessment of both sedation (1 = unarousable) and agitation (7 = dangerous agitation). According to protocol, regimens were titrated to achieve and maintain a Riker score of 4 (calm and cooperative). Deviation from a score of 4 during the course of treatment was compared between groups. RESULTS: Fifty patients met study criteria and were randomized after obtainment of informed consent (EtOH, n = 26; BENZO, n = 24). Overall, the EtOH group had a significantly greater proportion of patients who deviated from a score of 4 during the course of treatment (p = 0.020). In both groups, the majority of deviation from a score of 4 reflected periods of under-sedation rather than over-sedation. One patient in the EtOH group failed treatment, requiring diazepam and haloperidol for control of AWS symptoms as per protocol, whereas no patient in the BENZO group failed treatment (p = NS). CONCLUSION: Concerning the prophylaxis of AWS, intravenous ethanol offers no advantage over diazepam with respect to efficacy or adverse sedative effects. The purported benefit of intravenous ethanol as a prophylactic agent against AWS was not evident.

Alcohol Withdrawal Treatment Quiz:

1. Benzodizepines are the treatment of choice for alcohol withdrawal

A. True

B. False

2. Medications which have been studied for use in treating alcohol withdrawal include

A. Benzodiazepines

B. Phenobarbital

C. Carbamazepine

D. Baclofen

E. All of the above

3. Symptom-triggered alcohol withdrawal protocols use the following elements

A. Benzodiazepine generally as the agent for detoxification

B. Both objective and subjective items on a validated rating scale

C. Fixed dose administration of benzodiazepine

D. Both A and B

4. There is no need to look for other causes of delirium in the setting Delirium Tremens

A. True

B. False

5. Managing alcohol withdrawal delirum includes all of the following except:

A. Thiamine and other B vitamin supplementation

B. IV infusion of ethanol

C. Symptom-triggered or fixed dose protocols for using benzodiazepine

D. Being alert for other medical causes of delirium

Alcohol Withdrawal Treatment Quiz Key:

1. A

2. E

3. D

4. B

5. B

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