From the Guidelines
Benzodiazepines are the first-line treatment for alcohol withdrawal delirium tremens (DTs), not olanzapine. The preferred medications are long-acting benzodiazepines such as diazepam (5-10mg IV/PO every 1-4 hours as needed) or chlordiazepoxide (25-100mg PO every 4-6 hours as needed), administered using either a symptom-triggered or fixed-schedule approach, as recommended by the most recent guidelines 1. These medications work by enhancing GABA neurotransmission, which directly counteracts the CNS hyperexcitability caused by alcohol withdrawal.
Key Considerations
- Olanzapine and other antipsychotics should not be used as primary treatment for DTs because they lower the seizure threshold and do not address the underlying GABA-glutamate imbalance, as noted in the WHO guidelines 1.
- Antipsychotics may be used as adjuncts for severe agitation or hallucinations after benzodiazepines have been optimized.
- Treatment should occur in a monitored setting with regular vital sign checks, fluid replacement, thiamine supplementation (100mg IV/IM daily), and correction of electrolyte abnormalities.
- The Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar) should be used to monitor withdrawal severity and guide medication dosing, as supported by the ESMO clinical practice guidelines 1.
- Severe DTs require ICU admission due to the 5-10% mortality risk if untreated.
Additional Recommendations
- Patients at risk of severe withdrawal, or who have concurrent serious physical or psychiatric disorders, or who lack adequate support, should preferably be managed in an inpatient setting, as recommended by the WHO guidelines 1.
- Thiamine supplementation is crucial to prevent Wernicke's encephalopathy, especially in malnourished patients or those with suspected Wernicke's encephalopathy, as noted in the French Association for the Study of the Liver and the French Alcohol Society clinical guidelines 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. Anxiety or tension associated with the stress of everyday life usually does not require treatment with an anxiolytic 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, as it is indicated for the symptomatic relief of acute agitation, tremor, impending or acute delirium tremens and hallucinosis.
- Diazepam is a good option for managing DTs.
- Olanzapine is not mentioned in the provided drug label, therefore, its use for DTs cannot be assessed based on this information 2.
From the Research
Treatment for Delirium Tremens (DTs)
- The most effective treatment for delirium tremens (DTs) is benzodiazepines, particularly diazepam, due to their GABA-ergic effects 3, 4, 5.
- Diazepam has a faster onset of action than other benzodiazepines when administered intravenously and effectively controls symptoms of DTs 3.
- High-dose diazepam treatment may be required in the treatment of DTs that develop after long-term and high amounts of alcohol consumption 3, 6.
- Protocolized escalation of benzodiazepines as an alternative to a symptom-triggered approach may decrease the need for mechanical ventilation and intensive care unit (ICU) length of stay 4, 6.
Olanzapine as a Treatment Option
- There is no evidence to suggest that olanzapine is a preferred treatment option for delirium tremens (DTs) 3, 4, 7, 5, 6.
- Neuroleptics, such as olanzapine, may increase the risk of seizures and are not recommended as a first-line treatment for DTs 7.
- Benzodiazepines, particularly diazepam, are the treatment of choice for DTs, and other medications such as propofol may be considered for patients refractory to benzodiazepines 4.
General Support and Management
- General support, such as helping the patient to re-orientate, close monitoring of vital signs, and adequate hydration, is essential in the management of DTs 3.
- Individual support and effective communication seem to reduce the risk of severe withdrawal syndrome 7.
- Oral vitamin B1 supplementation is widely recommended to prevent serious complications in alcohol-dependent patients 7.