What is the management of alcohol withdrawal-induced delirium tremens (DTs)?

From the Guidelines

The management of delirium tremens requires prompt hospitalization and treatment with benzodiazepines, such as chlordiazepoxide, diazepam, or lorazepam, as outlined in the guidelines for the management of alcoholic liver disease 1. The treatment approach should prioritize the prevention of complications and the reduction of morbidity and mortality.

• Key considerations in the management of delirium tremens include:
  • Indications for admission, such as significant AWS, high levels of recent drinking, history of withdrawal seizures or delirium tremens, co-occurrence of a serious medical or psychiatric illness, or failure of outpatient treatment 1
  • Conservative treatment with fluids, electrolytes (especially magnesium), vitamins, and a comfortable environment 1
  • Pharmacological treatment with benzodiazepines, such as chlordiazepoxide (PO 25–100 mg every 4–6 hours), diazepam (PO/IV/IM 5–10 mg every 6–8 hours), or lorazepam (PO/IV/IM 1–4 mg every 4–8 hours) 1
  • Thiamine administration (100–300 mg/day for 4–12 weeks) to prevent Wernicke encephalopathy 1
  • The use of other drugs, such as carbamazepine or haloperidol, may be considered in specific cases, but should be used with caution and as adjunctive therapy only 1 The goal of treatment is to reduce the risk of morbidity and mortality associated with delirium tremens, which can be as high as 5-15% in untreated cases.
• The management of delirium tremens should be individualized and based on the patient's specific needs and medical history, with close monitoring of vital signs and neurological status. The use of benzodiazepines, such as diazepam or lorazepam, is recommended as the first-line treatment for delirium tremens, due to their effectiveness in reducing the risk of seizures and other complications 1.

From the FDA Drug Label

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. The management of delirium tremens involves the administration of diazepam (IV) at an initial dose of 10 mg, followed by 5 mg to 10 mg every 3 to 4 hours as needed 2.

• The dosage should be individualized for maximum beneficial effect.
• Intravenous administration is preferred, and facilities for respiratory assistance should be readily available.
• Lower doses should be used for elderly or debilitated patients and when other sedative drugs are administered.

From the Research

Management of Delirium Tremens

• Delirium Tremens (DT) is a severe spectrum of alcohol withdrawal that requires prompt and adequate management to prevent death 3.
• The assessment of DT includes evaluating the severity of alcohol withdrawal, delirium, and screening for underlying medical co-morbidities, with liver disease being a common co-morbidity 3.
• Benzodiazepines are the mainstay of treatment for DT, with diazepam and lorazepam being preferred options depending on the treatment regime and clinical context 3, 4.
• In benzodiazepine refractory cases, phenobarbital, propofol, and dexmedetomidine may be used 3.
• Treatment of DT is best achieved by the use of intravenous diazepam administered at frequent intervals while closely monitoring the patient 4.
• Refractory DT is defined by a high requirement of intravenous diazepam with poor control of withdrawal symptoms, and once the acute phase is medically controlled, the patient should be managed for their addiction to alcohol 4.
• Benzodiazepines have an established role in the management of delirium secondary to alcohol withdrawal, and their use in this setting is supported by evidence 5.
• However, the use of benzodiazepines in other settings, such as non-ICU delirium, is controversial and not recommended by current guidelines due to uncertainty about their effectiveness and potential harm 6.

Treatment Options

• Benzodiazepines, such as lorazepam, may be used in combination with other medications, such as haloperidol, to manage delirium in certain settings 5, 6.
• The effectiveness and safety of benzodiazepines in the treatment of delirium, excluding delirium related to withdrawal from alcohol or benzodiazepines, is uncertain and requires further research 6.
• Non-pharmacological strategies are recommended as the first line of treatment for delirium, with pharmacological interventions used to augment these approaches 6.

Clinical Considerations

• The pathophysiologic cause of delirium is not well understood, and its management is challenging due to the lack of a single effective intervention or medication 7.
• Recognizing patients at risk for delirium and promptly identifying and treating contributing factors is crucial to preventing and managing delirium 7.
• Multimodal strategies may be used to prevent or attenuate delirium, improving patient outcomes 7.