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

Abstract

achieved rapid symptom triggered tapering (in as little as nine hours 2 ). The inclusion of BS "prophylaxis" patients similarly conflated patients who required therapy with those who did not, or those who could similarly have achieved rapid tapering.The appropriateness of the assessment tools requires further explication, and the study appears underpowered and ill designed for adequate assessment of adverse events. Clonidine and dexmedetomidine predictably blunt adrenergic components of the CIWA-Ar and modified Minnesota Detoxification Scale assessment toolstremor, diaphoresis, pulse, diastolic pressure, etc.-making them appear "therapeutic" and improve AW, without addressing central pathophysiology. The trivial reported differences in daily CIWA-Ar (2.7 vs. 1.5), is likely explained by decreased scoring of assessment elements affected by clonidine. Analogously, beta-adrenergic antagonists demonstrably improved CIWA-Ar scores, but were abandoned as inappropriate AW therapy. Prediction of Alcohol Withdrawal Severity Scale score validation in trauma patients, who would be expected to have altered autonomic activity, should be referenced. The authors report clonidine discontinuation due "to relative hypotension," while setting the high bar for sequelae of acute kidney injury and vasopressors. Blood pressure and pulse decreases and orthostatics at the patient and population level (medians, range, maximums), need for volume resuscitation, additional pharmacological agents, and induced fall risk (so assiduously being avoided by BS) are omitted. In addition, AW measures that matter such as total days of required therapy; need for AW rescue medications; incidence of disorientation, agitation, seizures, hallucinations, and delirium tremens; restraint use; intubation for AW; and mortality in severe AW are unreported.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. AUTHORSHIPAll authors contributed to the study conception and design. All authors read and approved the final article as submitted. DISCLOSUREJTACS Disclosure forms have been supplied and are provided as supplemental digital content (http://links. lww.com/TA/D540).