Symptom-Triggered vs Fixed-Schedule Doses of Benzodiazepine for Alcohol Withdrawal

Daeppen, Jean‐Bernard; Gache, Pascal; Landry, Ulrika; Sekera, Eva; Schweizer, Verena; Gloor, Stéphane; Yersin, Bertrand

doi:10.1001/archinte.162.10.1117

Cited by 223 publications

(163 citation statements)

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“…Subsequent to that report, numerous studies have investigated route, dose, and method of administration. Specifically, administration of benzodiazepines in a symptom-triggered fashion results in less benzodiazepine utilization and shorter duration of therapy (4,5). However, these trials focused on subjects with relatively mild to moderate withdrawal who were stable enough to be treated in detoxification facilities or on the general medical ward.…”

Section: Discussionmentioning

confidence: 99%

“…Multiple studies suggest that administration of benzodiazepines in a symptom-triggered fashion both reduces the total amount of benzodiazepine administered and shortens the duration of therapy (4,5). In these studies, benzodiazepines are administered in repeated boluses (both intravenous and oral) of 10-20 mg of diazepam (or benzodiazepine equivalent) with current recommendations suggesting a maximal individual bolus of 20-30 mg of diazepam or benzodiazepine equivalent to be given until adequate sedation is achieved (4,6,7). Although widely accepted, these studies focus primarily on patients admitted to detoxification centers or the general hospital wards and exclude subjects admitted to the intensive care unit (ICU) (4,5).…”

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confidence: 99%

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A strategy of escalating doses of benzodiazepines and phenobarbital administration reduces the need for mechanical ventilation in delirium tremens*

Gold

Rimal

Nolan

et al. 2007

Critical Care Medicine

154

164

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Objective-Patients with severe alcohol withdrawal and delirium tremens are frequently resistant to standard doses of benzodiazepines. Case reports suggest that these patients have a high incidence of requiring intensive care and many require mechanical ventilation. However, few data exist on treatment strategies and outcomes for these subjects in the medical intensive care unit (ICU). Our goal was a) to describe the outcomes of patients admitted to the medical ICU solely for treatment of severe alcohol withdrawal and b) to determine whether a strategy of escalating doses of benzodiazepines in combination with phenobarbital would improve outcomes. Design-Retrospective cohort study.Setting-Inner-city municipal hospital.Patients-Subjects admitted to the medical ICU solely for the treatment of severe alcohol withdrawal. Interventions-Institution of guidelines emphasizing escalating doses of diazepam in combination with phenobarbital.Measurements and Main Results-Preguideline (n = 54) all subjects were treated with intermittent boluses of diazepam with an average total and maximal individual dose of 248 mg and 32 mg, respectively; 17% were treated with phenobarbital. Forty-seven percent required intubation due to inability to achieve adequate sedation and need for constant infusion of sedative-hypnotics. Intubated subjects had longer length of stay (5.6 vs. 3.4 days; p = .09) and higher incidence of nosocomial pneumonia (42 vs. 21% p = .08). Postguideline (n = 41) there were increases in maximum individual dose of diazepam (32 vs. 86 mg; p = .001), total amount of diazepam (248 vs. 562 mg; p = .001), and phenobarbital use (17 vs. 58%; p = .01). This was associated with a reduction in the need for mechanical ventilation (47 vs. 22%; p = .008), with trends toward reductions in ICU length of stay and nosocomial pneumonia.Conclusions-Patients admitted to a medical ICU solely for treatment of severe alcohol withdrawal have a high incidence of requiring mechanical ventilation. Guidelines emphasizing escalating bolus doses of diazepam, and barbiturates if necessary, significantly reduced the need for mechanical ventilation and showed trends toward reductions in ICU length of stay and nosocomial infections.

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

A strategy of escalating doses of benzodiazepines and phenobarbital administration reduces the need for mechanical ventilation in delirium tremens*

Gold

Rimal

Nolan

et al. 2007

Critical Care Medicine

154

164

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“…Such symptom-triggered treatment is generally preferred over fixed-dose regimens, 15 in part because when using this method, many cases of AWS can be managed with less medication. Benzodiazepine regimens using high doses have been found to be associated with substantial morbidity and prolonged hospitalizations.…”

mentioning

confidence: 99%

Treating alcohol withdrawal with oral baclofen: A randomized, double‐blind, placebo‐controlled trial

Lyon

Khan

Gessert

et al. 2011

Journal of Hospital Medicine

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BACKGROUND:Abrupt cessation of alcohol intake causes habituated drinkers to experience symptoms of alcohol withdrawal syndrome (AWS).OBJECTIVE:To determine the effect of the gamma‐aminobutyric acid (GABA)‐B agonist baclofen on the course of acute symptomatic AWS.DESIGN:Prospective, randomized, double‐blind, placebo‐controlled clinical study.SETTING:Two tertiary‐care hospitals in Duluth, Minnesota.PATIENTS:Inpatient adults admitted for any reason (including AWS) judged to be at high risk for AWS.INTERVENTION:Inpatients who developed symptoms of AWS received symptom‐triggered benzodiazepine treatment using lorazepam by standard protocol, and were randomized to receive baclofen 10 mg or placebo, 3 times per day, orally.MEASUREMENTS:AWS severity was assessed using the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA‐Ar); lorazepam dose was monitored.RESULTS:Seventy‐nine subjects were enrolled. The 44 subjects who developed symptoms of AWS were randomized to baclofen or placebo. Thirty‐one subjects (18 baclofen, 13 placebo) completed 72 hours of assessments, either entirely as inpatients or with outpatient follow‐up. The need for high doses of benzodiazepines (20 mg or more of lorazepam over 72 hours) to control AWS was less likely in the baclofen treatment group (1 of 18) than in the placebo‐treated group (7 of 13) (P = 0.004).CONCLUSIONS:We found that the use of baclofen was associated with a significant reduction in the use of high doses of benzodiazepine (lorazepam) in the management of symptomatic AWS. The use of low‐dose baclofen in the management of AWS deserves further study, as reduced dependence on high‐dose benzodiazepines in AWS management could improve patient safety. Journal of Hospital Medicine 2011;6:474–479. © 2011 Society of Hospital Medicine

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“…These include the ability to individualise treatment, reduction in treatment duration and reduced occurrence of delirium tremens [1,4]. Previous studies have shown equally efficacious results with a symptom triggered approach [5]. There is, however, a requirement of suitably trained staff [1].…”

Section: Introductionmentioning

confidence: 99%

Symptom Triggered Therapy in Delirium Tremens

Prakash

Setlur

2010

Medical Journal Armed Forces India

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Symptom-Triggered vs Fixed-Schedule Doses of Benzodiazepine for Alcohol Withdrawal

Abstract: Symptom-triggered benzodiazepine treatment for alcohol withdrawal is safe, comfortable, and associated with a decrease in the quantity of medication and duration of treatment.

Cited by 223 publications

References 15 publications

A strategy of escalating doses of benzodiazepines and phenobarbital administration reduces the need for mechanical ventilation in delirium tremens*

A strategy of escalating doses of benzodiazepines and phenobarbital administration reduces the need for mechanical ventilation in delirium tremens*

Treating alcohol withdrawal with oral baclofen: A randomized, double‐blind, placebo‐controlled trial

Symptom Triggered Therapy in Delirium Tremens

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