From the Guidelines
Benzodiazepines are the first-line medications for treating delirium tremens, with diazepam (Valium) and lorazepam (Ativan) being the most commonly used options. According to the most recent and highest quality study 1, benzodiazepines have a role as first-line agents in the management of alcohol or benzodiazepine withdrawal. The study suggests that benzodiazepines are effective at providing sedation and potentially anxiolysis in the acute management of severe symptomatic distress associated with delirium.
Key Points
- Diazepam is typically administered at 10-20mg IV every 1-4 hours as needed, while lorazepam is given at 2-4mg IV every 1-2 hours until symptoms are controlled.
- Lorazepam is preferred in patients with liver disease due to its shorter half-life and lack of active metabolites.
- Once the patient is stabilized, a tapering schedule should be implemented to prevent withdrawal recurrence.
- Adjunctive medications may include phenobarbital for refractory cases, antipsychotics like haloperidol for severe agitation or hallucinations, and clonidine to manage autonomic symptoms.
- Thiamine should always be administered to prevent Wernicke's encephalopathy.
Rationale
The use of benzodiazepines in the treatment of delirium tremens is supported by the evidence, which suggests that they are effective in reducing symptoms of withdrawal and improving patient outcomes 1. The choice of benzodiazepine depends on the patient's individual needs and medical history, with lorazepam being preferred in patients with liver disease. The use of adjunctive medications should be tailored to the patient's specific symptoms and needs.
Important Considerations
- Benzodiazepines should be used with caution in patients with a history of substance abuse or dependence.
- Patients should be closely monitored for signs of withdrawal and overdose.
- The use of benzodiazepines should be limited to the shortest duration possible to minimize the risk of dependence and withdrawal.
- Alternative treatments, such as antipsychotics and anxiolytics, should be considered in patients who are not responding to benzodiazepines or who have a history of substance abuse. However, as stated in 1, antipsychotics and anxiolytics should be avoided for first-line treatment of delirium unless benefits far outweigh known risks.
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 first-line medicine used in the treatment of delirium tremens (alcohol withdrawal syndrome) is diazepam (IV), with an initial dose of 10 mg intramuscular or intravenous, followed by 5 mg to 10 mg in 3 to 4 hours, if necessary 2 2.
From the Research
First-Line Medicines for Delirium Tremens
- Benzodiazepines are the mainstay of treatment for delirium tremens (DT) 3, 4, 5
- Preferred benzodiazepines include diazepam and lorazepam, depending on the treatment regime and clinical context 3
- In benzodiazepine refractory cases, other medications such as phenobarbital, propofol, and dexmedetomidine may be used 3, 6
Treatment Considerations
- The choice of treatment may be influenced by underlying medical co-morbidities, such as liver disease 3
- High-dose benzodiazepine use for an extended period may be necessary in some cases of delirium tremens 4
- Adjunctive medications, such as dexmedetomidine, may be used to reduce sympathetic over-activity and agitation in delirious patients 6