Diazepam pharmacokinetics after intravenous administration in alcohol withdrawal.

Alcohol withdrawal is commonly encountered in general hospital settings. It forms a major part of referrals received by a consultation-liaison psychiatrist. This article aims to review the evidence base for appropriate clinical management of the alcohol withdrawal syndrome. We searched Pubmed for articles published in English on pharmacological management of alcohol withdrawal in humans with no limit on the date of publication. Articles not relevant to clinical management were excluded based on the titles and abstract available. Full-text articles were obtained from this list and the cross-references. There were four meta-analyses, 9 systematic reviews, 26 review articles and other type of publications like textbooks. Alcohol withdrawal syndrome is a clinical diagnosis. It may vary in severity. Complicated alcohol withdrawal presents with hallucinations, seizures or delirium tremens. Benzodiazepines have the best evidence base in the treatment of alcohol withdrawal, followed by anticonvulsants. Clinical institutes withdrawal assessment-alcohol revised is useful with pitfalls in patients with medical comorbidities. Evidence favors an approach of symptom-monitored loading for severe withdrawals where an initial dose is guided by risk factors for complicated withdrawals and further dosing may be guided by withdrawal severity. Supportive care and use of vitamins is also discussed.

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“…Loading dose strategies use long acting benzodiazepines as they provide a self-tapering effect due to their pharmacokinetic properties. [ 25 ]…”

Section: Treatment Of Acute Alcohol Withdrawal Syndromementioning

confidence: 99%

Clinical management of alcohol withdrawal: A systematic review

2013

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“…Diazepam has a rapid onset of action and rapidly reaches its maximum concentration in the central nervous system (CNS) due to its highly lipophilic nature. Diazepam is metabolized by the liver to form the active metabolite, desmethyldiazepam (DMDZ) and both are slowly eliminated from the body . This slow elimination allows for prolonged therapeutic concentrations to exist even after short treatment durations.…”

Section: Introductionmentioning

confidence: 99%

The Role of Diazepam Loading for the Treatment of Alcohol Withdrawal Syndrome in Hospitalized Patients

et al. 2013

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Diazepam loading is an effective treatment option for hospitalized patients experiencing AWS. Diazepam loading uses the concept of symptom-triggered therapy, a mainstay of current AWS treatment, while exploiting its prolonged elimination half-life and eliminating the need for additional pharmacologic therapy. Studies reviewed found diazepam loading significantly improved a number of important outcomes in AWS, including time in DTs, compared to traditional treatment strategies.

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“…Patients fully treated in the ED with diazepam are protected from the serious manifestations of alcohol withdrawal and will not require outpatient benzodiazepine prescriptions. 5 Ideal management of AWS incorporates a symptom-driven approach, whereby patients are regularly assessed using a standardized scoring system. 6 The severity of alcohol withdrawal can be assessed using the Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) scale, a validated scale measuring withdrawal symptoms in ten individual domains.…”

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confidence: 99%

“…The 90‐hour half‐life of diazepam and its metabolites makes it an ideal choice for ED use. Patients fully treated in the ED with diazepam are protected from the serious manifestations of alcohol withdrawal and will not require outpatient benzodiazepine prescriptions …”

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confidence: 99%

Evaluation of a Web‐based Educational Program to Teach the Identification and Management of Alcohol Withdrawal in the Emergency Department

Thompson

McLeod

Perelman

et al. 2018

AEM Education and Training

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Background: Ideal management of alcohol withdrawal syndrome (AWS) incorporates a symptom-driven approach, where patients are regularly assessed using a standardized scoring system (Clinical Institute Withdrawal Assessment for Alcohol-Revised [CIWA-Ar]) and treated according to severity. Accurate administration of the CIWA-Ar requires experience, yet there is no training program to teach this competency. The objective of this study was to develop and evaluate a curriculum to teach clinicians how to accurately assess and treat AWS.Methods: This was a three-phase education program consisting of a series of e-learning modules containing core competency material, an in-person seminar to orient learners to high-fidelity simulation, and a summative evaluation in an objective structured clinical examination setting using a standardized patient. To determine the impact of the AWS curriculum, we recorded how often the CIWA-Ar was appropriately applied in the emergency department (ED) before and after training. A CIWA-Ar protocol breach was defined as inappropriate administration of benzodiazepines (CIWA-Ar < 10) and failure to administer benzodiazepines when required (CIWA-Ar ≥ 10). ED length of stay, amount of benzodiazepines administered in the ED, discharge prescriptions, and unit doses (takeaway bottle of four tablets) of benzodiazepine given were recorded.Results: Seventy-four ED nurses completed the curriculum over an 8-week period. In the 5 months prior to the educational program delivery, we identified 144 of 565 (25.5%) CIWA-Ar protocol breaches, compared to 64 of 547 (11.7%) in the 5 months after training (Δ13.8%, 95% confidence interval [CI] = 9.3%-18.3%). Program completion resulted in a reduction in the median total dose of diazepam administered in the ED (40 mg vs. 30 mg, Δ10 mg, 95% CI = 0-20 mg) and no change was detected in ED length of stay and benzodiazepines prescribed.Conclusions: Completion of this curriculum resulted in better compliance with the CIWA-Ar protocol by those who administer the CIWA-Ar; however, changes in inappropriate benzodiazepine prescribing practice will require future interdisciplinary initiatives.

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Diazepam pharmacokinetics after intravenous administration in alcohol withdrawal.

Cited by 8 publications

References 7 publications

Clinical management of alcohol withdrawal: A systematic review

Clinical management of alcohol withdrawal: A systematic review

The Role of Diazepam Loading for the Treatment of Alcohol Withdrawal Syndrome in Hospitalized Patients

Evaluation of a Web‐based Educational Program to Teach the Identification and Management of Alcohol Withdrawal in the Emergency Department

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