Controlled Trials Support the Use of Benzodiazepines for Prevention and Treatment of Alcohol Withdrawal Syndrome in the Intensive Care Unit

Alcohol withdrawal syndrome (AWS) is common in patients admitted to intensive care units (ICUs). Many drugs can be used to prevent or treat AWS in the ICU, but their relative advantages and disadvantages have not been systematically assessed. In this study, 2 independent working groups conducted a systematic review of controlled trials published from 1971 to March 2011 on prevention and treatment of AWS in the ICU. Six prevention trials (4 randomized, 2 nonrandomized) and 8 treatment trials (4 randomized, 4 nonrandomized) were identified. Drugs assessed for AWS prevention were ethanol infusion, clonidine, flunitrazepam, clomethiazol + haloperidol, flunitrazepam + haloperidol, and midazolam. Drugs assessed for AWS treatment included those listed above as well as gamma-hydroxybutyric acid, phenobarbital, lorazepam, and flunitrazepam + clonidine. Reasons for ICU admission were a mix of surgery, trauma, medical illness, and severe AWS. Definition and scoring of AWS and study outcome were highly heterogeneous across trials.

• All AWS prevention and treatment regimens were effective compared with control.
• Benzodiazepines were effective and safe for AWS prevention and treatment, whereas ethanol infusion was effective and safe for AWS prevention.

Comments:

The trials in this systematic review tended to be small and not high-quality, and heterogeneity prevented pooling of results. Nonetheless, I agree with the authors that benzodiazepines can be regarded as the standard of care for AWS prevention and treatment in the ICU. Although ethanol infusion was effective for AWS prevention, I do not believe it should supplant benzodiazepines because the level of evidence is weaker, it is difficult to titrate, and has no apparent benefit over benzodiazepines.

Kevin L. Kraemer, MD, MSc

Reference:

Ungur LA, Neuner B, John S, et al. Prevention and therapy of alcohol withdrawal on intensive care units: systematic review of controlled trials. Alcohol Clin Exp Res. 2013;37(4):675–686.