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

Immediate Pharmacological Management

Benzodiazepine Therapy (First-Line)

• Diazepam 10 mg IV initially, then 5-10 mg IV every 3-4 hours as needed for acute alcohol withdrawal, delirium tremens, agitation, tremor, and hallucinosis 2
• Administer slowly—at least one minute per 5 mg given—with respiratory assistance readily available 2
• Lorazepam is preferred over diazepam in elderly patients and those with advanced liver disease to reduce accumulation risk from active metabolites 1, 3
• Continue benzodiazepines until symptoms are controlled, typically for up to 7 days maximum 4

The evidence strongly supports benzodiazepines as superior to all other agents. They reduce seizure risk, prevent progression to severe withdrawal, and when combined with appropriate supportive care, reduce delirium tremens mortality to under 3% 4. Diazepam and lorazepam are both effective, but the choice depends on patient factors—particularly hepatic function and age 1, 3.

Adjunctive Antipsychotic Therapy

• Haloperidol 0.5-2 mg IV slow bolus may be added for persistent psychotic symptoms (hallucinations, severe agitation) that continue despite adequate benzodiazepine therapy 1
• Antipsychotics should never replace benzodiazepines but only supplement them, as benzodiazepines were more effective than neuroleptics in preventing delirium-related mortality 4
• Discontinue antipsychotics immediately once distressful symptoms resolve 5
• Monitor for extrapyramidal symptoms, QTc prolongation, and lowered seizure threshold 6

Critical caveat: The 2018 Critical Care Medicine guidelines recommend against routine use of haloperidol or atypical antipsychotics for treating delirium, as they do not shorten delirium duration or improve mortality 5. However, short-term use is warranted for patients with significant distress from hallucinations or delusion-associated fearfulness 5. This creates a nuanced approach: benzodiazepines alone for most cases, with haloperidol reserved for breakthrough psychotic symptoms.

Refractory Cases

• Phenobarbital, propofol, or dexmedetomidine may be used in benzodiazepine-refractory delirium tremens 3
• Dexmedetomidine specifically may help when agitation precludes weaning from mechanical ventilation 5

Essential Supportive Care

Immediate Corrections

• Correct dehydration, electrolyte disturbances (especially hypokalemia, hypomagnesemia), and glucose abnormalities, as these worsen delirium 1
• Avoid excessive fluid-sodium administration in patients with cardiac disease due to pulmonary edema risk 4
• Monitor vital signs continuously for autonomic instability 7

Thiamine Supplementation

• Administer high-dose oral vitamin B1 (thiamine) supplementation to all patients, as deficiency is frequent and can lead to Gayet-Wernicke encephalopathy 4
• Use IV thiamine for patients with very poor nutritional status or suspected Wernicke encephalopathy (a medical emergency), despite rare anaphylactic reaction risk 4
• High doses are necessary to compensate for poor absorption in alcohol-dependent patients 4

Non-Pharmacological Interventions

• Provide a quiet room with adequate lighting and minimize noise 7
• Display visible calendars and clocks for reorientation 7
• Maintain caregiver consistency and minimize room relocations 7
• Encourage family/friends at bedside and bring familiar objects from home 7
• Frequently reassure and reorient the patient using clear, simple language 7

These multicomponent strategies have been shown to reduce delirium duration, ICU length of stay, and hospital mortality 5.

Post-Acute Management

• Consider relapse prevention medications (acamprosate or naltrexone) after the acute withdrawal phase, though these are not useful during active withdrawal 1
• Avoid disulfiram in patients with liver disease due to hepatotoxicity risk 1
• Comprehensive inpatient addiction treatment following emergency stabilization results in better 6-month outcomes with fewer relapses compared to emergency treatment alone 8

Critical Monitoring Requirements

• Continuous respiratory monitoring, as benzodiazepines can cause respiratory depression 2
• Serial assessment using validated tools (CAM-ICU) to track delirium resolution 7, 9
• Watch for transition between hyperactive and hypoactive delirium subtypes 7
• Extreme caution in patients with chronic lung disease or unstable cardiovascular status 2

Common Pitfalls to Avoid

• Never use benzodiazepines alone without addressing underlying medical complications (infection, hypoxia, metabolic derangements) 7
• Do not use antipsychotics as monotherapy—they increase seizure risk and have higher mortality than benzodiazepines 4
• Avoid betablockers (increase hallucination risk) and clonidine (increases nightmare risk) 4
• Do not use acamprosate, naltrexone, or disulfiram during acute withdrawal 4
• Avoid physical restraints as first-line management 7