What is the best treatment for a client experiencing delirium tremens (DTs) from alcohol withdrawal?

From the Guidelines

The best treatment for a client experiencing delirium tremens (DTs) from alcohol withdrawal is immediate hospitalization with benzodiazepine therapy as the cornerstone of management. This approach is supported by the most recent and highest quality study, which emphasizes the importance of benzodiazepines in reducing withdrawal symptoms and the risk of seizures and delirium tremens 1. Typically, long-acting benzodiazepines like diazepam (5-10mg IV every 5-10 minutes until agitation is controlled, then 5-20mg every 1-4 hours as needed) or chlordiazepoxide (50-100mg orally every 6 hours, tapering over 3-5 days) are preferred. These medications work by enhancing GABA activity in the brain, which helps counteract the excessive neuronal excitation caused by alcohol withdrawal.

Some key points to consider in the management of DTs include:

• Vital signs should be continuously monitored, with IV fluids provided to address dehydration and electrolyte imbalances.
• Thiamine (100mg IV/IM daily for 3-5 days) must be administered to prevent Wernicke's encephalopathy.
• For severe cases or benzodiazepine-resistant DTs, adjunctive medications may include phenobarbital, propofol, or dexmedetomidine under close monitoring.
• Antipsychotics like haloperidol may help manage hallucinations but should not be used as primary treatment as they can lower seizure threshold.
• The treatment environment should be quiet with minimal stimulation, and restraints should be avoided if possible.
• After acute management, the patient should transition to a comprehensive alcohol treatment program to address the underlying alcohol use disorder.

It's worth noting that other studies, such as 1 and 1, also support the use of benzodiazepines as the primary treatment for DTs, but the most recent study 1 provides the most up-to-date guidance on this topic. Additionally, while other medications like topiramate and baclofen may have potential benefits in the treatment of alcohol withdrawal, the current evidence is not sufficient to recommend their use as a replacement for benzodiazepines 1.

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. In acute alcohol withdrawal, diazepam may be useful in the symptomatic relief of acute agitation, tremor, impending or acute delirium tremens and hallucinosis.

The best treatment for a client experiencing delirium tremens (DTs) from alcohol withdrawal is diazepam (IV), with an initial dose of 10 mg and subsequent doses of 5 mg to 10 mg in 3 to 4 hours, if necessary 2. This is based on the recommended dosage for acute alcohol withdrawal in the drug label. Diazepam is useful in the symptomatic relief of acute agitation, tremor, impending or acute delirium tremens, and hallucinosis 2.

From the Research

Treatment Options for Delirium Tremens (DTs)

The treatment for delirium tremens (DTs) typically involves a combination of general support and symptomatic treatment. According to 3, 4, 5, 6, benzodiazepines are the most commonly preferred treatment due to their GABA-ergic effects.

Benzodiazepines as a Treatment Option

• Diazepam is a suitable agent for severe alcohol withdrawal syndrome (AWS) or DT treatment, as it has a faster onset of action than other benzodiazepines when administered intravenously (iv) and effectively controls symptoms 3, 5.
• Lorazepam is also a preferred benzodiazepine, depending on the treatment regime and clinical context 4.
• High-dose diazepam treatment may be required in the treatment of DT that develops after long-term and high amounts of alcohol consumption 3.

Symptom-Driven Protocols

• A symptom-driven protocol using lorazepam can be effective in treating severe alcohol withdrawal delirium in the intensive care unit (ICU), resulting in decreased time to symptom control, amount of sedative required, and time spent receiving benzodiazepine infusion 7.
• Diazepam loading is a treatment strategy that utilizes the pharmacokinetics of this agent to achieve a rapid reduction in symptoms followed by sustained benefit over a period of days, and can be an effective treatment option for hospitalized patients experiencing AWS 6.

Important Considerations

• Severe AWS can potentially result in death if not managed quickly and adequately 3, 4.
• 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 4.
• Close monitoring is required to ensure protocol compliance and to avoid potential propylene glycol toxicity when using a symptom-driven protocol 7.