Baclofen Versus Diazepam to Treat Alcohol Withdrawal
Addolorato G, Leggio L, Abenavoli L, et al. Baclofen in the treatment of alcohol withdrawal syndrome: a comparative study vs diazepam. Am J Med. 2006 Mar;119 (3):276.e13-18.
Alcohol withdrawal syndrome (AWS) is a frequent problem encountered in hospitalized patients; its management is considered one of SHM’s core competencies for hospitalists. Benzodiazepines are the gold standard of therapy for this problem given their established record for safety and efficacy; however, their use can be problematic in certain instances.
This study involved 37 outpatients, as inpatients may often be sicker and at higher risk of severe withdrawal.
There is a definite risk of oversedation—especially in patients with COPD or chronic liver disease. Some patients require inordinately high doses of benzodiazepines, thus setting the stage for a prolonged hospitalization. Occasional paradoxical or disinhibition reactions to benzodiazepines can also be problematic. Addiction and or diversion are also a concern in patients prone to substance abuse. An otherwise stable patient, ready for discharge, may still be on a relatively high dose of lorazepam, but it is generally not prudent to send the patient out with a supply of medication to finish the course given concerns over resumption of drinking while on the sedative. Conversely, the solution can be cold comfort for the attending physician if the patient resumes drinking, thus eliminating the need for additional medication.
Baclofen, a stereoselective gamma-aminobutyric acid agonist, has a long history of safety in the treatment of spasticity. As such it can counter balance the activation of the glutamate excitatory pathway that characterizes AWS. It has been proposed as an alternative treatment for AWS that would not share the above concerns cited for benzodiazepines.
This study is a randomized controlled trial of baclofen versus valium in the treatment for AWS. Thirty-seven subjects with a history of heavy alcohol use were randomized to either baclofen 30 mg per day or valium 0.5 to 0.75 mg/kg. All were outpatients treated for 10 days. Clinical Institute Withdrawal Assessment-Alcohol (CIWA) scores were assessed daily. Both regimens continuously decreased the baseline elevation of CIWA scores daily over the course of the study, without a significant difference in treatment efficacy. No adverse events or side effects were reported in either group.
Other than baseline CIWA and daily alcohol consumption, it is not clear that the two groups were at equal risk for severe withdrawal reactions. Relevant baseline characteristics such as history of seizures or delirium tremens, factors that raise this risk were not noted.
Significance for hospitalists: With a long history of safety and efficacy, benzodiazepines remain the drugs of choice for hospitalists treating patients with AWS. In certain instances it may be desirable to limit or even avoid their use. How effective and safe baclofen would be in filling this role remains to be fully established. In particular the relative risk for sedation and respiratory depression has not been defined. Nevertheless at least in my institutions, as guided by expert consultation, its use has been carefully considered and proven helpful in some of the situations noted above. TH
