From the Guidelines
Delirium tremens requires immediate medical attention with benzodiazepines, such as lorazepam, as the first-line treatment, due to its potential to cause severe complications and death. The management of delirium tremens involves a comprehensive approach, including pharmacological treatment, close monitoring, and addressing comorbidities. According to the study by 1, lorazepam is recommended for patients with severe alcohol withdrawal syndrome, including delirium tremens, due to its intermediate-acting effects and lower risk of accumulation. The dosage of lorazepam should be started at 6-12 mg/day and tapered off following resolution of the withdrawal symptoms.
Key Considerations
- Delirium tremens is a serious complication of alcohol withdrawal syndrome, characterized by altered mental status, disorientation, and autonomic nervous system activation, as described in the study by 1.
- The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) can be helpful for evaluating the severity of alcohol withdrawal syndrome, but it is not recommended for diagnosis due to potential false positives in psychiatric conditions, as noted in the study by 1.
- Thiamine supplementation is essential for patients with alcohol withdrawal syndrome, including delirium tremens, to prevent diminished cognitive function due to thiamine deficiency, as recommended in the study by 1.
Treatment Approach
- Benzodiazepines, such as lorazepam, should be used as the first-line treatment for delirium tremens, with symptom-triggered dosing based on withdrawal severity.
- Close monitoring in a hospital setting is necessary, with vital sign checks, fluid replacement, and thiamine supplementation.
- Electrolyte imbalances, particularly magnesium and potassium, should be corrected to prevent further complications.
- In severe cases resistant to benzodiazepines, alternative treatments, such as phenobarbital or propofol, may be necessary, as mentioned in the example answer.
From the FDA Drug Label
Acute Alcohol Withdrawal: As an aid in symptomatic relief of acute agitation, tremor, impending or acute delirium tremens and hallucinosis. 10 mg, intramuscular or intravenous initially, then 5 mg to 10 mg in 3 to 4 hours, if necessary. The recommended dose of diazepam for delirium tremens is 10 mg intramuscular or intravenous initially, then 5 mg to 10 mg in 3 to 4 hours, if necessary 2.
From the Research
Definition and Prevalence of Delirium Tremens
- Delirium Tremens (DT) is a severe spectrum of alcohol withdrawal that can potentially result in death if not managed promptly and adequately 3.
- The prevalence of DT in the general population is less than 1% and nearly 2% in patients with alcohol dependence 3.
- DT presents with a combination of severe alcohol withdrawal symptoms and symptoms of delirium with agitation and sometimes hallucination 3.
Assessment and Management of Delirium Tremens
- Assessment of DT includes assessment of severity of alcohol withdrawal, evaluation of delirium, and screening for underlying medical co-morbidities 3.
- Liver disease as a co-morbidity is very common in patients with DT and can complicate the clinical presentation, determine the treatment choice, and influence the outcome 3.
- Benzodiazepines are the mainstay of treatment for DT, with diazepam and lorazepam being preferred benzodiazepines depending on the treatment regime and clinical context 3, 4, 5.
- In benzodiazepine refractory cases, phenobarbital, propofol, and dexmedetomidine can be used 3.
Delirium and Its Association with Delirium Tremens
- Delirium is an acute confusional state that is common and costly, and is associated with significant functional decline and distress 6.
- Delirium tremens is a specific type of delirium occurring in patients who are in alcohol withdrawal states 4.
- The pathophysiologic cause of delirium is not well understood, and there is no single intervention or medication to treat delirium, making it challenging to manage 6.
Treatment and Mortality Rate of Delirium Tremens
- The treatment of DT is best achieved by the use of intravenous diazepam administered at frequent intervals while closely monitoring the patient during the procedure 4.
- Delirium tremens has a high mortality rate of about 8% 4.
- Refractory DT is defined by a high requirement of intravenous diazepam with poor control of withdrawal symptoms 4.
- Once the acute phase is medically controlled, the patient should be managed for their addiction to alcohol 4.