Delirium tremens medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Zehra Malik, M.B.B.S[2]

Overview

The mainstay of delirium tremens treatment is supportive care and sedatives. Benzodiazepines are the initial choice for sedation. To establish a consistent serum level, long-acting benzodiazepines such as diazepam and chlordiazepoxide are favored over short-acting benzodiazepines.

Medical Therapy

• Supportive care and sedation are the mainstay of treatment for delirium tremens.
• For sedation, benzodiazepines are the first choice.
• Long-acting benzodiazepines such as, diazepam and chlordiazepoxide are preferred over short-acting benzodiazepine to achieve a stable serum level.
• There are three approved techniques for the use of benzodiazepines in these patients to achieve an optimum level of sedation or to lower the CIWA score to <8: The techniques are:
  • Front loading (Most preferred)
    • 5 mg IV Diazepam administered twice with interval of 10 mins
    • 10 mg IV Diazepam administered twice with interval of 10 mins
    • 20 mg IV Diazepam administered twice with interval of 10 mins
    • 5-20 mg IV per hour.
  • This regimen is followed until the goal of light sedation of CIWA score of <8 is achieved.
  • Symptom-triggered
    • 10–20 mg IV diazepam administered every 1–4 hours until the treatment goal is met.
    • If using lorazepam, then 4 mg IV should be administered every 10 minutes.
  • Fixed-dose (Least preferred)
    • Used only for alcohol withdrawal syndrome in an outpatient setting.

Contraindication: In case of liver impairment or lack of IV access, lorazepam is preferred over diazepam.

Pharmacotherapy is symptomatic and supportive. Typically the patient is kept sedated with benzodiazepines, such as diazepam (Valium), lorazepam (Ativan) or oxazepam (Serax) and in extreme cases low-levels of antipsychotics, such as haloperidol until symptoms subside. Older drugs such as paraldehyde and clomethiazole were the traditional treatment but these have now largely been superseded by the benzodiazepines, although they may still be used as an alternative in some circumstances. Acamprosate is often used to augment treatment, and is then carried on into long term use to reduce the risk of relapse. If status epilepticus is present, seizures are treated accordingly. Controlling environmental stimuli can also be helpful, such as a well-lit but relaxing environment to minimize visual misinterpretations such as the visual hallucinations mentioned above.