From the Guidelines
Delirium tremens (DTs) is a severe manifestation of alcohol withdrawal syndrome that occurs due to neurochemical imbalances following cessation of chronic alcohol use, primarily affecting GABA and glutamate neurotransmitter systems, as described in the 2013 study by 1. The pathophysiology of DTs centers on the sudden removal of alcohol's depressive effects on the central nervous system. During chronic alcohol exposure, the brain adapts by downregulating GABA receptors and upregulating glutamate receptors. When alcohol is abruptly discontinued, this adaptation results in a hyperexcitable state characterized by reduced inhibition and increased excitation.
Key Factors Contributing to DTs
- The sympathetic nervous system becomes overactive, leading to autonomic instability with tachycardia, hypertension, hyperthermia, and diaphoresis, as noted in the 2012 study by 2.
- Alcohol withdrawal affects dopamine, serotonin, and norepinephrine systems, contributing to hallucinations, agitation, and confusion.
- Metabolic disturbances, including electrolyte abnormalities (particularly magnesium, phosphate, and thiamine deficiencies), further complicate the condition, with thiamine deficiency being especially critical as it can lead to Wernicke's encephalopathy, as highlighted in the 2013 study by 1.
Clinical Manifestation
The resulting neuronal hyperexcitability manifests clinically as:
- Tremors
- Seizures
- Autonomic instability
- Altered mental status Typically, these symptoms peak 48-72 hours after the last drink and can become life-threatening without proper medical management, emphasizing the need for timely and appropriate intervention, as discussed in the studies by 2 and 1.
From the FDA Drug Label
As an aid in symptomatic relief of acute agitation, tremor, impending or acute delirium tremens and hallucinosis. The FDA drug label does not answer the question.
From the Research
Pathophysiology of Delirium Tremens (DT)
The pathophysiology of Delirium Tremens (DT) is complex and involves multiple factors. DT is a severe form of alcohol withdrawal that can be life-threatening if not managed promptly and adequately 3, 4. The condition is characterized by a combination of severe alcohol withdrawal symptoms and symptoms of delirium, including agitation, hallucinations, and clouded consciousness 3, 4.
Clinical Features
The clinical features of DT include:
- Tremor, sweating, hypertension, and tachycardia 4
- Clouded consciousness, disorientation, and disturbed circadian rhythms 4
- Thought process and sensory disturbances, which can fluctuate over time 4
- Hallucinations and agitation 3
Treatment
The treatment of DT typically involves a combination of supportive and symptomatic approaches. Benzodiazepines, such as diazepam and lorazepam, are commonly used to manage DT 3, 4, 5. In some cases, other medications like phenobarbital, propofol, and dexmedetomidine may be used 3. Supportive therapy is also important, and may include vital signs monitoring, medication review, and management of underlying medical co-morbidities 4, 6.
Underlying Mechanisms
The underlying mechanisms of DT are not fully understood, but are thought to involve multiple neurobiological processes, including:
- Neuroinflammation 6
- Brain vascular dysfunction 6
- Altered brain metabolism 6
- Neurotransmitter imbalance 6
- Impaired neuronal network connectivity 6
Management Strategies
The effective management of DT requires a multidomain approach that focuses on: