Eliminating the benzos: A benzodiazepine-sparing approach to preventing and treating alcohol withdrawal syndrome

Abstract

Background Alcohol withdrawal syndrome (AWS) represents significant cost to the hospitalized trauma population from a clinical and financial perspective. Historically, AWS has been managed with benzodiazepines. Despite their efficacy, benzodiazepines carry a heavy side effect profile. Recently, benzodiazepine sparing protocols for the prophylaxis and treatment of AWS have been used in medical patient populations. Most existing benzodiazepine-sparing protocols utilize phenobarbital while ours primarily utilizes gabapentin and clonidine, and no such protocol has been developed and examined for safety and efficacy specifically within a trauma population. Methods In December of 2019, we implemented our benzodiazepine-sparing protocol for trauma patients identified at risk for alcohol withdrawal on admission. Trauma patients at risk for AWS admitted to an academic Level 1 trauma center before (CONV) and after (BS) protocol implementation were compared. Outcomes examined include morphine milligram equivalent (MME) dosing rates, lorazepam equivalent dosing rates as well as the Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) scores, hospital length of stay (LOS), ICU (Intensive Care Unit) LOS, and ventilator days. Results 387 conventional (CONV) and 134 benzodiazepine sparing (BS) patients were compared. ISS (13 vs 16, p = 0.10) and admission alcohol levels (99 vs 149, p = 0.06) were similar. Patients in the BS pathway had a lower maximum daily CIWA-Ar (2.7 vs 1.5, p = 0.04). While mean MME/day was not different between groups (31.5 vs 33.6, p = 0.49), mean lorazepam equivalents per day was significantly lower in the BS group (1.1 vs 0.2, p < 0.01). LOS and vent days were not different between the groups. Conclusions Implementation of a benzodiazepine-sparing pathway that utilizes primarily clonidine and gabapentin to prevent and treat alcohol withdrawal syndrome in trauma patients is safe, reduces the daily maximum CIWA-Ar, and significantly decreases the need for benzodiazepines. Future studies will focus on outcomes affected by avoiding AWS and benzodiazepines in the trauma population. Level of Evidence IV, Therapeutic/care management

Reply to letter to the editor: Eliminating the benzos: A benzodiazepine-sparing approach to preventing and treating alcohol withdrawal syndrome

“…W e have reviewed the Letter to the Editor by Klein et al in response to our recent publication "Eliminating the Benzos: A Benzodiazepine-Sparing Approach to Preventing and Treating Alcohol Withdrawal Syndrome" and sincerely appreciate the opportunity to respond. 1 We were more than a little surprised by the authors' statement that our article "represents an inherent misunderstanding of the pathophysiology" of alcohol withdrawal syndrome (AWS). A more thoughtful review of our article and protocol might reveal that this is perhaps overstated.…”

Response to: “Eliminating the benzos: A benzodiazepine-sparing approach to preventing and treating alcohol withdrawal syndrome”

“…W e have reviewed the Letter to the Editor by Klein et al in response to our recent publication "Eliminating the Benzos: A Benzodiazepine-Sparing Approach to Preventing and Treating Alcohol Withdrawal Syndrome" and sincerely appreciate the opportunity to respond. 1 We were more than a little surprised by the authors' statement that our article "represents an inherent misunderstanding of the pathophysiology" of alcohol withdrawal syndrome (AWS). A more thoughtful review of our article and protocol might reveal that this is perhaps overstated.…”

“…To the Editor: W e read McCullough and colleagues' "Eliminating the Benzos" with interest. 1 The authors retrospectively assessed medical records to evaluate the implications of a hospital-wide benzodiazepine-sparing (BS) alcohol withdrawal (AW) treatment protocol, which consisted of gabapentin, clonidine, valproic acid (VPA), and dexmedetomidine. We have several concerns regarding methodology and interpretation.…”

“…The BS protocol is not a "major advancement in the care of AWS." 1 It presents a methodologically confounded abandonment of efficacious, patient-triggered therapies, administration of multiple potentially unneeded, inferior, or demonstrably harmful agents, and a regression to a "q shift," provider-centered mentality, which the authors ultimately demonstrated was harmful, at a minimum, to ICUAW patients. We urge institutions to adopt a patient-centered approach with proven symptom-triggered agents with appropriate adjuvants.…”