What is the treatment for delirium tremens?

Treatment of Delirium Tremens

Benzodiazepines are the gold standard first-line treatment for delirium tremens, with diazepam or lorazepam as preferred agents, administered intravenously in escalating doses until symptom control is achieved. 1, 2, 3

Initial Assessment and Diagnosis

• Recognize the clinical presentation: DT manifests with severe alcohol withdrawal symptoms combined with delirium, agitation, tremor, hallucinations, and altered consciousness, typically occurring in alcohol-dependent patients who abruptly stop drinking 3, 4
• Identify high-risk patients: Those with chronic heavy drinking history, previous delirium tremens episodes, or prior generalized seizures are at highest risk for developing DT 4
• Monitor vital signs continuously: DT is a medical emergency with mortality approaching 15% if untreated, requiring intensive care unit-level monitoring 3, 5

Pharmacological Management

Benzodiazepines (First-Line Treatment)

Diazepam (preferred for most patients):

• Initial dose: 10 mg IV or IM, then 5-10 mg every 3-4 hours as needed 2
• Titrate aggressively: In severe cases, doses up to 20 mg IV may be required, with slow administration (at least 1 minute per 5 mg) 2
• Advantages: Long-acting formulation provides better protection against seizures and prevents progression to more severe withdrawal 1, 3

Lorazepam (preferred for elderly or hepatic dysfunction):

• Use short-acting benzodiazepines in elderly patients and those with advanced liver disease to reduce accumulation risk 1, 6
• Dosing: 2-5 mg IV/IM initially, repeated as needed 1

Benzodiazepine-Refractory Cases

If inadequate response to high-dose benzodiazepines:

• Phenobarbital: Can be added for refractory cases 3
• Propofol infusion: Effective for benzodiazepine-resistant DT, but requires ICU setting with mechanical ventilation capability 3, 5
• Dexmedetomidine: May be considered as adjunctive therapy 3

Antipsychotic Therapy (Adjunctive Only)

Haloperidol for psychotic symptoms:

• Indication: Use only when hallucinations or severe agitation persist despite benzodiazepine therapy 1, 6
• Dosing: 0.5-2 mg IV slow bolus initially, can be repeated 1
• Critical warning: Never use antipsychotics as monotherapy—they lower seizure threshold and increase mortality when used alone 4, 6
• Monitor for: QTc prolongation, extrapyramidal symptoms, and neuroleptic malignant syndrome 1, 6

Essential Supportive Care

Thiamine Supplementation (Mandatory)

• Administer immediately: Give thiamine BEFORE any glucose-containing fluids to prevent Wernicke encephalopathy 4
• Route selection: Intravenous administration for patients with poor nutritional status, severe withdrawal, or suspected Wernicke encephalopathy (despite rare anaphylactic risk) 4
• Oral dosing: High doses required due to poor absorption in alcohol-dependent patients 4

Fluid and Electrolyte Management

• Monitor carefully: Avoid excessive water-sodium intake, which risks pulmonary edema in patients with cardiac disease 4
• Correct imbalances: Address dehydration, hypo/hyperglycemia, and electrolyte disturbances as these can worsen delirium 1

Treatment Setting and Monitoring

ICU-level care required:

• Continuous monitoring of vital signs, respiratory status, and level of consciousness 3, 5
• Respiratory support readily available: Benzodiazepines and propofol carry respiratory depression risk 2, 5
• Current mortality rate: Under 3% with appropriate intensive monitoring and support 4

Common Pitfalls to Avoid

• Never use benzodiazepines alone without addressing underlying causes: Screen for infections, metabolic disturbances, and other medical complications 1
• Avoid neuroleptics as first-line therapy: They increase seizure risk and mortality when used without benzodiazepines 4, 6
• Don't use inadequate benzodiazepine doses: Aggressive titration is necessary; underdosing leads to treatment failure 3
• Never discharge after emergency stabilization alone: Patients receiving only emergency treatment have significantly higher relapse rates (70% vs 48%) compared to those receiving comprehensive inpatient addiction treatment 7

Post-Acute Management

After DT resolution:

• Transition to comprehensive addiction treatment: Emergency management alone results in poor 6-month outcomes with high relapse rates 7
• Consider relapse prevention medications: Acamprosate or naltrexone after acute withdrawal phase (though not useful during active withdrawal) 1, 4
• Avoid disulfiram in liver disease: Contraindicated due to hepatotoxicity risk 1