What is the treatment for delirium tremens (DTs)?

From the Guidelines

The treatment for delirium tremens requires immediate medical attention in a hospital setting, with benzodiazepines being the first-line treatment, as recommended by the most recent guidelines 1.

Key Considerations

• Benzodiazepines, such as diazepam or lorazepam, are the most commonly used medications to control seizures, reduce agitation, and prevent progression of symptoms.
• A symptom-triggered approach using the Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar) is often used to guide dosing.
• Supportive care includes IV fluids for dehydration, thiamine to prevent Wernicke's encephalopathy, folate supplementation, and correction of electrolyte imbalances, particularly magnesium and potassium.

Medication Options

• Diazepam (10-20mg IV initially, then 5-10mg every 1-4 hours as needed) or lorazepam (2-4mg IV initially, then 1-2mg every 1-4 hours) are commonly used benzodiazepines.
• Other medications, such as carbamazepine or haloperidol, may be used as adjunctive therapy in specific cases, but their use should be carefully considered due to potential side effects and interactions 1.

Monitoring and Follow-up

• Close monitoring of vital signs and neurological status is essential, as patients may require intensive care for severe cases.
• After acute management, patients should transition to a comprehensive alcohol treatment program to prevent recurrence, as delirium tremens has a mortality rate of 1-4% even with proper treatment.

Additional Considerations

• The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) is helpful for evaluating the severity of AWS, but high scores may be seen in psychiatric conditions that are similar to AWS, such as anxiolytic withdrawal, anxiety disorder, and physical conditions such as sepsis, hepatic encephalopathy, and severe pain 1.
• Thiamine should be given to all patients with AWS (100-300 mg/day) and maintained for 2-3 months following resolution of their withdrawal symptoms to prevent Wernicke's encephalopathy 1.

From the FDA Drug Label

In acute alcohol withdrawal, diazepam may be useful in the symptomatic relief of acute agitation, tremor, impending or acute delirium tremens and hallucinosis Diazepam is useful for the symptomatic relief of acute delirium tremens.

• The treatment is for short-term relief of symptoms.
• Diazepam may be used for the relief of tremor and agitation associated with delirium tremens. 2

From the Research

Treatment for Delirium Tremors

• The treatment for delirium tremors typically involves the use of benzodiazepines, with diazepam and lorazepam being the preferred options 3, 4.
• Benzodiazepines are effective in managing the symptoms of delirium tremors, including agitation and hallucinations 3, 5.
• In cases where benzodiazepines are not effective, other medications such as phenobarbital, propofol, and dexmedetomidine may be used 3.
• The treatment of delirium tremors should also involve the management of underlying medical co-morbidities, such as liver disease, which can complicate the clinical presentation and influence the outcome 3.
• It is essential to closely monitor the patient during treatment, as delirium tremors can be life-threatening if not managed promptly and adequately 4.

Benzodiazepines in Delirium Treatment

• Benzodiazepines have an established role in the management of delirium secondary to alcohol withdrawal 5.
• However, their use in the treatment of non-alcohol withdrawal related delirium is controversial, and current guidelines do not recommend their use for this indication 6, 7.
• There is limited evidence to support the effectiveness of benzodiazepines in the treatment of delirium in non-ICU settings, and further research is required to determine their role in this context 6, 7.