Practice Guidelines for Managing Alcohol Withdrawal Delirium

Alcohol
withdrawal delirium can cause serious morbidity and mortality if
not treated appropriately. To inform clinical practice, researchers
conducted a structured review and meta-analysis (including 9 prospective
controlled trials) and developed evidence-based guidelines for
managing alcohol withdrawal delirium.

Compared
with neuroleptics, sedative-hypnotics were more effective at decreasing
mortality (in 2 trials that had any deaths), and at shortening
the duration of delirium (in 3 of 4 trials). In 2 studies reporting
the time required to control agitation, intravenous diazepam was
better than paraldehyde per rectum in 1, but intramuscular diazepam
was no different from oral barbital in the other.

Based
on these findings and review of other data, the researchers recommended
the following:

• providing
  comprehensive monitoring and supportive care
• using parenteral,
  rapid-acting sedative-hypnotics (preferably benzodiazepines due
  to their more favorable therapeutic/toxic index) to achieve light
  sedation
• considering
  pentobarbital or propofol if agitation is not controlled with
  initial large doses of benzodiazepines (based on case reports)
• considering
  neuroleptics only when the patient has continued agitation, disturbed
  thinking, or perceptual disturbances despite sedative-hypnotic
  treatment

Comments:

The

practice guidelines outlined in this paper are very practical

and reasonable. Although the studies examined are limited

(the 9 trials were all published before 1979, 5 of the
9

included fewer than 20 subjects per treatment group, and

conclusions about mortality were based on only 9 deaths),

the evidence and years of clinical experience with these

drugs support the use of sedative-hypnotics, primarily
benzodiazepines,

for alcohol withdrawal delirium.

Kevin
L. Kraemer, MD, MSc

Reference:

Mayo-Smith

MF, Beecher LH, Fischer TL, et al. Management of alcohol

withdrawal delirium: an evidence-based practice guideline.

Arch Intern Med. 2004;164(13):1405–1412.
(view
abstract)