What medications are used to treat delirium tremens (alcohol withdrawal syndrome)?

From the Guidelines

Benzodiazepines are the first-line treatment for delirium tremens, with diazepam and lorazepam being the most commonly used medications. According to the most recent and highest quality study 1, benzodiazepines are effective at providing sedation and potentially anxiolysis in the acute management of severe symptomatic distress associated with delirium. The study also notes that benzodiazepines have a role as first-line agents in the management of alcohol or benzodiazepine withdrawal.

Medication Administration

Diazepam is typically administered at 10-20mg IV every 1-4 hours as needed, while lorazepam is given at 2-4mg IV every 1-4 hours as needed, with dosing adjusted based on symptom severity. For patients with liver disease, lorazepam is preferred due to its shorter half-life and lack of active metabolites.

Adjunctive Treatments

Adjunctive treatments include thiamine (100mg IV/IM daily for 3-5 days) to prevent Wernicke's encephalopathy, folate supplementation, and correction of electrolyte abnormalities, particularly magnesium and potassium.

Supportive Care

Supportive care with IV fluids, glucose administration, and close monitoring of vital signs is essential. Benzodiazepines work by enhancing GABA activity in the brain, which helps counteract the excessive neuronal excitation caused by alcohol withdrawal.

Antipsychotics

Antipsychotics like haloperidol may help manage agitation and hallucinations but should not be used as primary treatment as they can lower the seizure threshold, as noted in the study 1. The study 1 also suggests that olanzapine, quetiapine, and aripiprazole may offer benefit in the symptomatic management of delirium, but benzodiazepines are preferred for delirium tremens.

Treatment Duration

Treatment should continue until symptoms resolve, with gradual tapering to prevent withdrawal recurrence. In severe cases resistant to benzodiazepines, phenobarbital (65-130mg IV) may be added.

It's worth noting that the use of pharmacological interventions in the management of delirium should be limited to patients who have distressing delirium symptoms or if there are safety concerns where the patient is a potential risk to themselves or others, as stated in the study 1. Medications should be used in the lowest effective dose and for a short period of time only.

From the FDA Drug Label

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

Diazepam is used to treat delirium tremens (alcohol withdrawal syndrome). It is available in both IV 2 and PO 3 forms. The medication is used for the symptomatic relief of:

• Acute agitation
• Tremor
• Impending or acute delirium tremens
• Hallucinosis

From the Research

Medications for Delirium Tremens

The primary medications used to treat delirium tremens (alcohol withdrawal syndrome) include:

• Benzodiazepines, which are the mainstay of treatment 4, 5, 6
• Specific benzodiazepines used are:
  • Diazepam 4, 5
  • Lorazepam 4, 6
  • Midazolam 5, 6
• In benzodiazepine refractory cases, other medications can be used:
  • Phenobarbital 4
  • Propofol 4, 7
  • Dexmedetomidine 4

Treatment Approach

The treatment approach for delirium tremens involves:

• Assessment of severity of alcohol withdrawal 4
• Evaluation of delirium 4
• Screening for underlying medical co-morbidities 4
• Use of benzodiazepines as first-line treatment 4, 8
• Consideration of other medications in refractory cases 4, 7