A number of alternative non-sedative-hypnotic medications exist to treat acute alcohol withdrawal. Beta-adrenergic blockers (atenolol, propranolol), clonidine, and anticonvulsant agents (carbamazepine, valproate) decrease alcohol withdrawal symptoms and have been used successfully in the treatment of mild withdrawal. They are not cross-tolerant with alcohol, however, and may result in progression of the withdrawal syndrome. These alternative medications are not appropriate to use as single agents in the treatment of withdrawal in a general medical setting.
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Dosing regimens: There are no standard protocols for withdrawal management in widespread use.12 A fixed dosing schedule is commonly used for treatment of acute withdrawal, but either fixed-schedule or symptom-triggered dosing—medication given as needed for withdrawal signs—is efficacious in the treatment of withdrawal, even in patients with medical comorbidity.6
Fixed-schedule dosing is a one-size-fits-all approach for treating alcohol withdrawal. It uses the same dose of cross-tolerant medication on a fixed schedule for all patients for 24-48 hours; the dose is then tapered if the patient is stable. (See Table 2, left.) Reducing the dose by 10%-20% of the initial dose each day over five to 10 days provides a comfortable taper—especially in patients who initially required higher doses of medication to control the withdrawal. Fixed-schedule dosing offers less flexibility for individual patients, but it is a simple approach that can be applied in many settings.
Symptom-triggered therapy occurs when cross-tolerant medication is given only for symptoms of withdrawal rather than on a schedule. (See Table 3, p. 25.) Patients are monitored closely and assessed regularly using a tool such as the CIWA-Ar. The dose of cross-tolerant medication prescribed is based on the severity of withdrawal symptoms as measured by the CIWA-Ar score. This approach is similar to the sliding scale of insulin dosing used to treat hyperglycemia. Symptom-triggered therapy provides individualized treatment for withdrawal without overmedicating or underdosing, but it is a complex system to carry out on a general medical unit.
Severe withdrawal: Treat severe DTs manifested by abnormal and fluctuating vital signs and/or delirium aggressively in an ICU environment with sufficiently large doses of medication to suppress the withdrawal.11 Use IV medications with a rapid onset of action for immediate effect. Lorazepam and diazepam have a rapid onset of action when given intravenously, although the duration of action is shorter than when given orally.
For example, give lorazepam in a dose of one to four mg every 10-30 minutes until the patient is calm but awake and the heart rate is below 120 beats per minute. A continuous intravenous infusion may be warranted to control withdrawal symptoms, and the rate can be titrated to the desired level of consciousness. After stabilization, the patient can be changed to an equivalent dose of a long-acting sedative-hypnotic and tapered as above.
Assessing and medicating acute withdrawal remain necessary first steps in the treatment of the disease of alcohol dependence. After acute detoxification has begun, long-term treatment of alcoholism is necessary to prevent readmission for continuing medical problems due to alcohol consumption. Refer patients who have been treated for alcohol withdrawal for long-term treatment of alcoholism. This may include Alcoholics Anonymous, outpatient counseling, and other treatment modalities.
Conclusion
Ask all patients admitted to the hospital about drinking alcohol and be alert for signs of acute alcohol withdrawal in any patient. The best predictor of whether a patient will develop acute withdrawal is a past history of withdrawal. Signs of withdrawal usually occur within 48 hours of the last drink. Untreated withdrawal may result in significant morbidity and mortality.
Patients in withdrawal should be monitored closely and given appropriate doses of benzodiazepines or barbiturates to treat withdrawal signs. Cross-tolerant medication may be given on a fixed schedule or as symptom-triggered therapy. Severe withdrawal may require a continuous intravenous infusion in an ICU. Recognition and effective treatment of alcohol withdrawal can prevent significant complications in hospitalized patients. TH