Symptom-Triggered Therapy for Alcohol Withdrawal Syndrome: a Systematic Review and Meta-analysis of Randomized Controlled Trials

Holleck, Jürgen L; Merchant, Nazakat; Gunderson, Craig G.

doi:10.1007/s11606-019-04899-7

Cited by 31 publications

(29 citation statements)

References 27 publications

(47 reference statements)

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“…On admission and at discharge we collected the number of prescribed medications; the number, molecules and dosages of BZRA ( Appendix 1 ); and the number and molecules of other psychotropic drugs (N02A, N03A, N04, N05A, N05C, N06A-C-D). BZRA dosages were converted into lorazepam-equivalent doses using a conversion table [ 30 , 31 ], so that molecules could be compared at baseline and between admission and discharge. Polypharmacy was defined as regular use of 5 or more drugs [ 32 ] and excessive polypharmacy as use of 10 or more drugs [ 33 ].…”

Section: Methodsmentioning

confidence: 99%

Current practice in benzodiazepine receptor agonists deprescribing on acute geriatric wards: a cohort study

et al. 2022

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Background Benzodiazepine receptor agonist (BZRA) use is highly prevalent in hospitalised older people although these drugs are associated with numerous and serious adverse events. Deprescribing can reduce risks associated with chronic BZRA use. The aim of this study was to measure the prevalence of, and factors associated with, BZRA deprescribing in acute geriatric units. Methods During a one-year period, this multicentre retrospective study included patients aged ≥70 years, hospitalised in acute geriatric units, and using ≥1 BZRA on admission. BZRA deprescribing at discharge was defined as: ≥25% decrease in lorazepam-equivalent admission dose; discontinuation of all BZRAs; or cessation of a rescue prescription at discharge. BZRA cessation was defined as discontinuation of all BZRAs at discharge. We identified social, medical, geriatric and medication factors associated with BZRA deprescribing using logistic regression. Results In total, 561 patients were included (mean age: 85.3±5.9 years, 70% of women). BZRA deprescribing occurred in 240 (42.8%), including 85 with BZRA cessation (15.2%). Deprescribing occurred more frequently in patients with a BZRA-related adverse event on admission or during hospital stay (odds ratio (OR) 4.5; 95% confidence interval [2.6; 7.9]), with an antidepressant (1.6 [1.1; 2.4]) and a higher lorazepam-equivalent dosage on admission (OR 1.2 [1; 1.4]), and less frequently in patients with antipsychotic drug (OR 0.5 [0.3; 0.8]). BZRA cessation was more likely in patients with a BZRA-related adverse event (OR 2.2 [1.2; 4.3]) and a lower lorazepam-equivalent dosage on admission (OR 0.5 [0.3; 0.6]). Conclusions During hospitalisation in the acute geriatric units of our hospital, BZRA deprescribing occurred in 42.8% of the patients. Identification of an BZRA-related adverse event by the treating physician appears to be a major factor: this reactive deprescribing accounted for 74% of cases in our study. Further prospective studies are needed to measure long-term persistence of in-hospital deprescribing and encourage proactive management.

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Section: Methodsmentioning

confidence: 99%

Current practice in benzodiazepine receptor agonists deprescribing on acute geriatric wards: a cohort study

et al. 2022

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“…8,9 There are two well-known strategies for the treatment of alcohol withdrawal with benzodiazepines: first, a fixed schedule regimen with additional per-need doses depending on symptoms; second, a symptom triggered regimen by which benzodiazepines are administered according to the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) dosing protocol. 8 An alcohol rehabilitation program is an essential intervention to improve care for people suffering from alcohol-related disorders. 10 Like other Arabic countries, drug and alcohol abuse is a growing health issue in Oman, especially among young males.…”

Section: Conflict Of Interest: Nonementioning

confidence: 99%

Clinical characteristics and health outcomes in patients with alcohol withdrawal syndrome: an observational study from Oman

et al. 2022

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BACKGROUND: Globally, alcohol withdrawal syndrome (AWS) is considered a serious medical diagnosis associated with increasing morbidity and mortality. Little information has been reported on the scope of the problem in Oman. OBJECTIVE: Study clinical characteristics, management, quality of care, and health outcomes of patients managed for AWS. DESIGN: Retrospective medical record review. SETTINGS: University hospital. PATIENTS AND METHODS: The study included all patients with AWS admitted from 1 October 2019 to 30 September 2020. We collected demographic and clinical characteristics and did a univariate analysis of factors related to 90-day readmission. MAIN OUTCOME MEASURES: Length of hospital stay, 90-day read-mission, referral rate to alcohol rehabilitation center. SAMPLE SIZE AND CHARACTERISTICS: 150 male patients with median (IQR) age of 39.5 (32-48) years. RESULTS: Most patients (70.7%, n=106) were smokers and 44 (29.3%) had a history of drug abuse. The average length of hospital stay was 2.3 (0.9-4.6) days. Approximately 9% of total hospital bed days were used to care for patients with AWS. Chronic liver disease (35.3%), diabetes mellitus (24.7%), and hypertension (24.0%) were common among AWS patients. The 90-day readmission rate (32.7%) was high, and there was low referral to alcohol rehabilitation (16.7%). Diabetes and epilepsy were associated with 90-day readmission. CONCLUSION: AWS is an important diagnosis that represents an important burden on acute medical services. Establishing a drug and alcohol service in our institution is an essential step to optimise care for patients with alcohol-related disorders. LIMITATIONS: Retrospective, so unable to collect data on manifestations of AWS such as delirium tremens, which is the most severe form of AWS. Also, the reason for the lack of referral to an outpatient alcohol rehabilitation program was not apparent. CONFLICT OF INTEREST: None.

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“…A systematic review [51] found moderate strength evidence for symptom-triggered therapy reducing the duration of MAW and total benzodiazepine dose. However, this mainly applies to lower risk patients in specialized settings, and it is less clear that the process is useful in general hospital settings.…”

Section: Fixed-dose Versus Symptom-triggered Regimensmentioning

confidence: 99%

“…However, this mainly applies to lower risk patients in specialized settings, and it is less clear that the process is useful in general hospital settings. There is insufficient evidence to support symptom-triggered therapy producing better outcomes in terms of mortality, seizure control or delirium in any setting [51]. NICE guidance recommends a fixed-dose regimen for community-based withdrawal [26], a fixed-dose regimen with 'as needed' medication in specialist services and a 'symptom-triggered' regimen within a general medical inpatient setting [9].…”

Section: Fixed-dose Versus Symptom-triggered Regimensmentioning

confidence: 99%

Clinical management of the alcohol withdrawal syndrome

Day

Daly

2021

Addiction

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Up to half of individuals with a history of long-term, heavy alcohol consumption will experience the alcohol withdrawal syndrome (AWS) when consumption is significantly decreased or stopped. In its most severe form, AWS can be life-threatening. Medically assisted withdrawal (MAW) often forms the first part of a treatment pathway. This clinical review discusses key elements of the clinical management of MAW, necessary adjustments for pregnancy and older adults, likely outcome of an episode of MAW, factors that might prevent completion of the MAW process and ways of overcoming barriers to ongoing treatment of alcohol use disorder. The review also discusses the use of benzodiazepines in MAW. Although there is clear evidence for their use, benzodiazepines have been associated with abuse liability, blunting of cognition, interactions with depressant drugs, craving, delirium, dementia and disrupted sleep patterns. Because glutamatergic activation and glutamate receptor upregulation contribute to alcohol withdrawal, anti-glutamatergic strategies for MAW and other potential treatment innovations are also considered.

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Symptom-Triggered Therapy for Alcohol Withdrawal Syndrome: a Systematic Review and Meta-analysis of Randomized Controlled Trials

Cited by 31 publications

References 27 publications

Current practice in benzodiazepine receptor agonists deprescribing on acute geriatric wards: a cohort study

Current practice in benzodiazepine receptor agonists deprescribing on acute geriatric wards: a cohort study

Clinical characteristics and health outcomes in patients with alcohol withdrawal syndrome: an observational study from Oman

Clinical management of the alcohol withdrawal syndrome

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