What is the next step in managing a patient with severe alcohol withdrawal symptoms who remains symptomatic despite being on the maximum dose of Valium (diazepam) as per the Clinical Institute Withdrawal Assessment (CIWA) protocol?

From the Guidelines

For a patient with severe alcohol withdrawal symptoms who remains symptomatic despite maximum diazepam dosing per CIWA protocol, the next step is to consider alternative benzodiazepines, such as lorazepam or oxazepam, which are safer in patients with hepatic dysfunction, as recommended by 1. This approach is based on the fact that benzodiazepines are the gold standard treatment for alcohol withdrawal syndrome (AWS), and long-acting benzodiazepines may not be suitable for patients with hepatic dysfunction 1. Some key points to consider in the management of these patients include:

• The use of short-acting benzodiazepines, such as lorazepam or oxazepam, which are preferred in patients with cirrhosis due to the risk of drug accumulation and encephalopathy 1
• The importance of monitoring for signs of Wernicke's encephalopathy and prescribing thiamine as part of the withdrawal process, as recommended by 1
• The potential need for adjunctive therapies, such as phenobarbital, in refractory cases, as well as supportive care, including aggressive fluid repletion, electrolyte replacement, and continuous cardiac monitoring 1 It is essential to prioritize the patient's safety and well-being, and to be aware of the potential risks and benefits of different treatment options, as highlighted by 1. In terms of specific medications, lorazepam is a suitable alternative to diazepam, given its shorter half-life and lower risk of accumulation in patients with hepatic dysfunction, as noted in 1. Ultimately, the goal of treatment is to manage the patient's symptoms, prevent complications, and promote a safe and successful withdrawal from alcohol, as emphasized by 1.

From the Research

Management of Severe Alcohol Withdrawal

• The Clinical Institute Withdrawal Assessment (CIWA) protocol is used to manage alcohol withdrawal symptoms, with benzodiazepines, such as diazepam, being the primary treatment option 2, 3.
• In cases where patients remain symptomatic despite being on the maximum dose of diazepam, alternative treatment options may be considered.
• Propofol is a viable alternative for patients refractory to benzodiazepines, as it has been shown to be effective in managing severe alcohol withdrawal symptoms 2, 3.
• Phenobarbital may also be considered as an alternative treatment option, as it has been shown to reduce the need for mechanical ventilation and lead to shorter ICU stays 4.

Treatment Options

• Benzodiazepines, such as diazepam, remain the treatment of choice for alcohol withdrawal symptoms, with protocolized escalation being an alternative to a symptom-triggered approach 2.
• Propofol, phenobarbital, and other agents, such as dexmedetomidine and ketamine, may be considered for patients who are refractory to benzodiazepines, although their roles are not yet clearly defined 2, 3, 4.
• The choice of treatment option should be guided by the patient's individual needs and medical history, as well as the availability of resources and expertise.

Considerations

• The use of CIWA-Ar protocols in general hospitals requires careful consideration of validated alcohol withdrawal risk factors, exclusion of patients who cannot communicate, and continuity of care during transitions 5.
• The judicious use of benzodiazepines and other treatment options is essential to minimize the risk of adverse events, such as respiratory depression and agitation 5.