Title

Can We Treat Alcohol Withdrawal In A Safer Way?


Authors

Ritesh P Shrestha, MBBS1

Farshid Fargahi, MD1

Himanshu Rawal, MBBS1

Eskandar Alex Yazaji, MD1

1] Medstar Union Memorial Hospital


Introduction

Alcohol withdrawal syndrome occurs in patients who have become chronically alcohol dependent and then undergo abrupt alcohol cessation. Benzodiazepines have been the treatment of choice for the management of alcohol withdrawal for long time; however; benzodiazepines can be associated with serious side effects. Recent studies have suggested that anticonvulsants can be used as an adjunctive therapy to traditional benzodiazepines in management of alcohol withdrawal. The objective of this study is to evaluate the efficacy of anticonvulsants in reducing the severity and duration of alcohol withdrawal, compared to benzodiazepines alone.


Methods

We developed a new alcohol withdrawal protocol with anticonvulsants including gabapentin, divalproex sodium, or valproic acid. Patients admitted to the intermediate care unit (IMCU) at our community teaching hospital with presumed diagnosis of alcohol dependence and at risk of withdrawal were enrolled in the study. Between June 2016 and March 2017, all patients admitted to the IMCU were randomized to either the standard benzodiazepine-based protocol (control group) or the anticonvulsant-based protocol (intervention group). Patients were assessed daily for any signs of delirium using the Confusion Assessment Method (CAM). Data was extracted from the electronic medical record and included the Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score as well as benzodiazepine requirements (calculated in lorazepam equivalent dose).


Results

There were 44 patients in the control group and 31 patients in the intervention group. There were no significant differences in demographics such as age and race, amount and type of alcohol consumption, or the history of alcohol withdrawal. The median and interquartile ratio (IQR) of severity of CIWA scores in the control and intervention groups was 3 (0.9, 5) and 0.8 (0.2, 3.3), respectively (p=0.01). The median and IQR for benzodiazepine requirements for patients in the control and intervention group prior to randomization were 0.0 (0,1) and 1.00 (0, 2) mg, respectively (p=0.22). The median and IQR of benzodiazepine requirements after the patients were admitted to IMCU were 7 (0.2, 15) mg in the control versus 0 (0, 4) mg in the intervention group (p<0.001). The median and IQR of the duration of benzodiazepine therapy was significantly lower in intervention group compared to control group, (0 [0, 2] versus 2[0, 4] days, p <0.001). The median and IQR of CIWA score after randomization were 3 (1, 5) in the control versus 1 (1, 3) in the intervention group (p<0.001). The number of patients who developed delirium in the control group was 7 versus no patients in the intervention group (p=0.04).


Conclusion

Adjuvant therapy with anticonvulsants is efficacious in reducing the severity of alcohol withdrawal and benzodiazepine requirement.


References

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