What is the management for a 37-year-old man with a high Substance Abuse Summit Hall (SASH) score indicating severe alcohol withdrawal?

From the Guidelines

Management for a 37-year-old man with a high SASH score indicating severe alcohol withdrawal requires immediate hospitalization, preferably in an intensive care unit, with benzodiazepine therapy as the cornerstone of treatment, as recommended by the most recent guidelines 1. The patient should be treated with a symptom-triggered approach using the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale, administering lorazepam 2-4 mg IV every 1-2 hours as needed for CIWA scores above 8-10, as this approach has been shown to be effective in managing alcohol withdrawal symptoms 1.

• Benzodiazepines, such as diazepam or lorazepam, are the first-line options for treating alcohol withdrawal, due to their efficacy in reducing withdrawal symptoms and preventing seizures and delirium tremens 1.
• Thiamine supplementation (100 mg IV three times daily for 3-5 days) is essential to prevent Wernicke's encephalopathy, a potentially life-threatening complication of alcohol withdrawal 1.
• Fluid repletion with IV normal saline and correction of electrolyte abnormalities, particularly magnesium, potassium, and phosphate, should be implemented to prevent further complications 1.
• Seizure prophylaxis may require additional anticonvulsants if seizures occur despite benzodiazepine therapy, and for severe, refractory cases, phenobarbital or propofol infusion may be necessary 1.
• Close monitoring of vital signs, mental status, and withdrawal symptoms is crucial, as severe withdrawal can progress to delirium tremens, which carries a mortality rate of 1-4% even with treatment 1.
• Following acute management, the patient should be evaluated for long-term alcohol use disorder treatment, including counseling and possibly medications such as acamprosate, naltrexone, or disulfiram 1.

From the FDA Drug Label

Diazepam is indicated for the management of anxiety disorders or for the short-term relief of the symptoms of anxiety. ... In acute alcohol withdrawal, diazepam may be useful in the symptomatic relief of acute agitation, tremor, impending or acute delirium tremens and hallucinosis.

The management for a 37-year-old man with a high Substance Abuse Summit Hall (SASH) score indicating severe alcohol withdrawal may include the use of diazepam (IV) for the symptomatic relief of acute agitation, tremor, impending or acute delirium tremens, and hallucinosis.

• The patient should be closely monitored due to the risks associated with diazepam use.
• Diazepam may be useful as part of the treatment plan, but the overall management of the patient should be individualized and may involve other interventions as well 2.

From the Research

Management of Severe Alcohol Withdrawal

The management of a 37-year-old man with a high Substance Abuse Summit Hall (SASH) score indicating severe alcohol withdrawal involves the use of benzodiazepines as the primary treatment option.

• Benzodiazepines such as diazepam, lorazepam, chlordiazepoxide, and oxazepam are commonly used to ameliorate or prevent the symptoms and complications of moderate to severe alcohol withdrawal 3.
• Diazepam has been suggested as the preferred benzodiazepine for the treatment of patients experiencing moderate to severe alcohol withdrawal due to its rapid onset of action and long elimination half-life, which allows for a smoother withdrawal 3, 4.
• A symptom-triggered approach to benzodiazepine administration is often used, where the dose and frequency of administration are adjusted based on the patient's symptoms 5.
• In some cases, phenobarbital may be used as an adjunctive therapy for severe alcohol withdrawal, particularly in patients who do not respond to benzodiazepines alone 6, 7.
• Other medications such as propofol, dexmedetomidine, and anticonvulsants may also be used in certain situations, such as in patients who are refractory to benzodiazepines or have specific comorbidities 7, 5.

Treatment Considerations

When managing severe alcohol withdrawal, it is essential to consider the following:

• The patient's medical history, including any liver disease or other comorbidities that may affect the metabolism and clearance of benzodiazepines 3, 5.
• The potential for over-sedation and the need for close monitoring of the patient's vital signs and symptoms 3, 5.
• The importance of a comprehensive treatment plan that includes supportive care, such as hydration, nutrition, and counseling, in addition to pharmacological treatment 5.
• The possibility of complications, such as seizures and delirium tremens, and the need for prompt recognition and treatment of these conditions 7, 5.