It is unclear if attention is given to the initiation of longer-term treatment of the underlying alcohol use disorder (AUD) with evidence-based agents such as disulfiram, naltrexone, and acamprosate, with the relapse prevention goal of reduction or cessation of alcohol use. Inpatient management on acute medical units is often focused on the patient’s acute withdrawal symptoms. ( 23) A systematic review found that there was insufficient evidence to support the use of valproic acid for prevention and treatment of AWS. ( 19) Small double-blind, placebo-controlled RCTs using divalproex for AWS have shown mixed results, with one RCT showing benefit in decreasing AWS symptoms, ( 22) while the other found no difference over the placebo. ( 21) Gabapentin is generally well tolerated, considered safer due to few adverse events, has fewer drug–drug interactions than other ACs (e.g., carbamazepine), and can be used in those with hepatic impairment. ( 20) A recent meta-analysis found moderate evidence to support gabapentin’s use in both AWS and the reduction of cravings in dependence however, limitations include a small number of studies with modest sample sizes and variable dosing regimens. ( 17, 19) Lower doses of gabapentin were found to be helpful in mild AWS symptoms, but not for more severe symptomatology. ( 17– 19) Relatively high doses of gabapentin (1200–3200 mg/day) may be required to see a positive effect in non-elderly patients, with low doses unlikely to provide sufficient anti-seizure protection. ( 15) Gabapentin was found to be helpful in the outpatient setting for mild-to-moderate AWS, ( 16, 17) but it has not consistently demonstrated effectiveness in severe AWS or in inpatient settings.
/is-this-normal-how-long-will-it-last-80197_final-01-61e907a86b19467487b731d369f8c978.png "alcohol withdrawal syndrome medication")
#Alcohol withdrawal syndrome medication trial#
( 9, 13, 14) A randomized controlled trial (RCT) comparing carbamazepine and lorazepam in the outpatient setting found both to be effective, but carbamazepine also significantly reduced drinking in the post-treatment period. ( 10, 11, 13)įor ACs, double-blind studies suggest carbamazepine may be as effective as lorazepam for symptom management however, it has significant gastrointestinal and neurotoxic side effects. ( 8, 10, 11) While there is limited evidence to support AC monotherapy in the inpatient setting for moderate-to-severe AWS, ( 12, 13) adjunctive therapy with carbamazepine, gabapentin, or divalproex has shown benefits. ACs enhance GABAergic transmission, provide anti-kindling effects, possibly provide seizure protection, and may be continued as treatment for AUD. ( 10, 11) In light of this, the use of adjunctive anticonvulsants (ACs) to manage AWS has been investigated. ( 7) This class of medication is not without its potential adverse effects in the hospitalized elderly, such as oversedation, respiratory depression, delirium, and falls. ( 9)īenzodiazepines remain the gold standard pharmacotherapy for AWS as they reduce symptoms and are neuroprotective against seizures and delirium tremens. ( 5) Patients with repeated episodes of AWS are at risk for increased neuronal sensitivity known as the kindling effect, which leads to more severe subsequent episodes with risk of complications. ( 8) Adults over the age of 60 are at increased risk for these severe complications due to medical comorbidities, cognitive deficits, and concurrent pharmacotherapies.
( 6, 7) Symptoms include tremor, diaphoresis, anxiety, nausea, or insomnia, while severe complications include hallucinations, seizures, delirium tremens, and death. ( 6) This contributes to alcohol withdrawal syndrome (AWS) developing within 6 to 24 hours after abrupt alcohol cessation. ( 3, 5) Chronic alcohol exposure leads to down-regulation of inhibitory gamma-aminobutyric acid type A (GABA-A) receptors and up-regulation of excitatory glutamate in the N-methyl-D aspartate (NMDA) receptors. ( 4) It is estimated that 1–3% of community-dwelling adults over the age of 60 meet the criteria for alcohol use disorder (AUD), while the estimate increases up to 30% in those hospitalized. ( 1– 3) The National Health Survey in 2012 found 50% of men and 39% of women endorsed daily alcohol consumption. Excessive alcohol consumption is an underlying factor for a myriad of health complications including cancer, cognitive impairment, and psychiatric comorbidity.
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