What is the treatment for delirium tremens?

Treatment of Delirium Tremens

Benzodiazepines are the gold standard treatment for delirium tremens, with intravenous diazepam 10 mg initially, followed by 5-10 mg every 3-4 hours as the preferred first-line approach, combined with immediate thiamine 100-500 mg IV before any glucose administration. 1, 2, 3, 4

Immediate Assessment and Stabilization

Critical First Steps

• Administer thiamine 100-500 mg IV immediately BEFORE any glucose-containing fluids to prevent precipitating Wernicke encephalopathy 1, 5
• Monitor vital signs continuously for autonomic instability including tachycardia, hypertension, hyperthermia, and sweating 1, 3
• Assess for life-threatening complications: dehydration, severe electrolyte imbalances (especially magnesium), infection, sepsis, hepatic encephalopathy, gastrointestinal bleeding, and renal failure 6, 1

Setting of Care

• Delirium tremens must be managed in an ICU or ward with continuous vital signs monitoring due to risk of malignant arrhythmia, respiratory arrest, prolonged seizures, and sudden death 3, 4

Pharmacological Management

First-Line Treatment: Benzodiazepines

Diazepam is the preferred benzodiazepine due to its rapid onset when given intravenously and superior protection against seizures and delirium tremens compared to shorter-acting agents 1, 2, 4, 7

Diazepam Dosing Protocol

• Initial dose: 10 mg IV, then 5-10 mg IV every 3-4 hours as needed 1, 2
• Inject slowly, taking at least one minute for each 5 mg given 2
• For severe cases, doses may need to be escalated significantly - case reports document successful treatment with 260-480 mg/day in refractory delirium tremens 7, 8
• Maximum initial dose up to 30 mg may be given, with repeat dosing every 2-4 hours if necessary 2

Alternative Benzodiazepines

• Lorazepam 6-12 mg/day is preferred if hepatic dysfunction is present, as it has a shorter half-life and no active metabolites 6, 1, 5
• Lorazepam may also be added for agitation refractory to high-dose neuroleptics 6

Important Contraindications

• Do NOT use antipsychotics (haloperidol, risperidone) as first-line treatment for delirium tremens - recent evidence shows they provide no benefit in mild-to-moderate delirium and may worsen symptoms 6
• Antipsychotics should only be considered if there are distressing perceptual disturbances (hallucinations) causing severe agitation that threatens patient or staff safety, and only after benzodiazepines have been optimized 6

Refractory Cases

If symptoms persist despite high-dose benzodiazepines (>200 mg diazepam equivalent/day):

• Phenobarbital: 1-3 mg/kg IV bolus, followed by 0.5 mg/kg/h infusion, with usual maintenance 50-100 mg/h 6, 4
• Propofol infusion: Consider as adjuvant therapy when benzodiazepines alone are insufficient 4, 9
• Dexmedetomidine: May be used in benzodiazepine-refractory cases 4

Critical warning: Do not withhold large benzodiazepine doses due to fear of side effects - extremely high doses for extended periods may be necessary, and undertreating increases mortality 8

Essential Supportive Care

Thiamine and Nutritional Support

• Continue thiamine 100-300 mg/day for 2-3 months following resolution 1, 5
• Administer thiamine BEFORE any glucose-containing IV fluids 1, 5

Fluid and Electrolyte Management

• Aggressive fluid replacement with careful attention to magnesium levels, which are commonly depleted in chronic alcohol use 1
• Monitor and correct hypokalemia, hypophosphatemia, and hypomagnesemia 6, 1

Monitoring Requirements

• Continuous vital signs monitoring including temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation 1, 3
• Assess for concurrent infections or metabolic derangements that may complicate presentation 1

Common Pitfalls to Avoid

• Never administer glucose before thiamine - this can precipitate acute Wernicke encephalopathy 1, 5
• Do not use anticonvulsants alone for alcohol withdrawal seizures - benzodiazepines are required 5
• Avoid using antipsychotics as monotherapy - they do not prevent seizures or reduce mortality 6
• Do not underdose benzodiazepines - inadequate dosing increases risk of progression to seizures and death 3, 8
• Benzodiazepines should not be continued beyond 10-14 days due to abuse potential 1

Post-Acute Management

• Psychiatric consultation is mandatory after stabilization for evaluation, ongoing treatment planning, and long-term abstinence strategies 6, 1
• Consider relapse prevention medications such as acamprosate, baclofen, or topiramate after withdrawal period 1, 5