Written by Peter Liu
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For alcohol withdrawal, a symptom-triggered benzodiazepine dosing approach shortened treatment duration and reduced total dosage compared to a fixed dosing approach.
For most patients with alcohol withdrawal, dose by symptoms
For inpatient alcohol withdrawal, there are two landmark RCTs on chlordiazepoxide and oxazepam symptom-triggered benzodiazepines dosing. Here, we focus on the oxazepam trial.
This double-blind RCT of 117 alcohol-dependent patients compared symptom-triggered and fixed-schedule benzodiazepine regimens in two Swiss university hospitals. The symptom-triggered group:
- received much less oxazepam (mean 37.5 mg vs. 231.4 mg, P<0.001).
- had shorter treatment duration (20.0 vs. 62.7 hours, P<0.001).
- had higher CIWA-Ar (alcohol withdrawal) scores but similar wellness scores on day 3.
- had similar, low rates of alcohol withdrawal complications, though one seizure occurred in the symptom-triggered group.
Current ASAM guidelines for alcohol withdrawal still recognize fixed-dose and front-loading strategies, where a high dose of long-acting benzodiazepine is administered initially in certain settings due to trial limitations:
- The trials were performed in specialty units trained to monitor for signs of clinical withdrawal.
- Patients that had profound autonomic dysregulation or other inpatient hospital needs were likely triaged elsewhere and underrepresented.
- Patients with severe alcohol withdrawal (e.g. CIWA-Ar>15) were poorly represented.
As a result, fixed dosing strategies may still be optimal in settings where clinical withdrawal scores are impractical to track or confounded by other clinical factors. Additionally, front-loading benzodiazepines may still be beneficial in minimizing withdrawal complications in patients with extremely elevated withdrawal scores or complication risk.
How does this change my practice?
In general, I follow the ASAM guidelines in my own clinical practice, with a strong preference for symptom-triggered benzodiazepine administration in the majority of alcohol withdrawal cases, but with room for the addition of front-loading, or with the option to switch to a fixed-dose strategy when CIWA-Ar monitoring is impractical, or when risk of complication is particularly high.
Editor’s note: CIWA is cumbersome. Could a modified RASS replace CIWA? The simple mRASS-AW worked in one Canadian hospital. ~Clay Smith
Source
Symptom-triggered vs fixed-schedule doses of benzodiazepine for alcohol withdrawal: a randomized treatment trial. Arch Intern Med. 2002 May 27;162(10):1117-21. doi: 10.1001/archinte.162.10.1117. PMID: 12020181
