Review of adjunctive dexmedetomidine in the management of severe acute alcohol withdrawal syndrome

Wong, Adrian; Smithburger, Pamela L.; Kane‐Gill, Sandra L.

doi:10.3109/00952990.2015.1058390

Cited by 16 publications

(14 citation statements)

References 40 publications

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“…Acute alcoholic hepatitis was defined as an admission aspartate aminotransferase (AST) greater than the upper limit of normal of our laboratory (AST > 37 IU/l). Dexmedetomidine and benzodiazepines were administered according to our hospital’s CIWA protocol (Clinical Institute Withdrawal Assessment for Alcohol Scale) [2, 4, 21, 22]. Survival to hospital discharge was recorded.…”

Section: Methodsmentioning

confidence: 99%

Adding an orange to the banana bag: vitamin C deficiency is common in alcohol use disorders

Marik

Liggett

2019

Crit Care

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Background At least a third of the world’s population consumes alcohol regularly. Patients with alcohol use disorders (AUDs) are frequently hospitalized for both alcohol-related and unrelated medical conditions. It is well recognized that patients with an AUD are thiamine deficient with thiamine replacement therapy being considered the standard of care. However, the incidence of vitamin C deficiency in this patient population has been poorly defined. Methods In this retrospective, observational study, we recorded the admission vitamin C level in patients with an AUD admitted to our medical intensive care unit (MICU) over a 1-year period. In addition, we recorded relevant clinical and laboratory data including the day 2 and day 3 vitamin C level following empiric treatment with vitamin C. Septic patients were excluded from this study. Results Sixty-nine patients met the inclusion criteria for this study. The patients’ mean age was 53 ± 14 years; 52 patients (75%) were males. Severe alcohol withdrawal syndrome was the commonest admitting diagnosis (46%). Eighteen patients (26%) had cirrhosis as the admitting diagnosis with 18 (13%) patients admitted due to alcohol/drug intoxication. Forty-six patients (67%) had evidence of acute alcoholic hepatitis. The mean admission vitamin C level was 17.0 ± 18.1 μmol/l (normal 40–60 μmol/l). Sixty-one (88%) patients had a level less than 40 μmol/l (subnormal) while 52 patients (75%) had hypovitaminosis C (level < 23 μmol/l). None of the variables recorded predicted the vitamin C level. Various vitamin C replacement dosing strategies were used. A 1.5-g loading dose, followed by 500-mg PO q 6, was effective in restoring blood levels to normal by day 2. Conclusion Our results suggest that hypovitaminosis C is exceedingly common in patients with an AUD admitted to an intensive care unit and that all such patients should receive supplementation with vitamin C in addition to thiamine. Additional studies are required to confirm the findings of our observational study and to determine the optimal vitamin C dosing strategy.

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Section: Methodsmentioning

confidence: 99%

Adding an orange to the banana bag: vitamin C deficiency is common in alcohol use disorders

Marik

Liggett

2019

Crit Care

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“…[3][4][5] Numerous medications in combination or as monotherapy are used for treatment of AW, including α-adrenergic agonists, barbiturates, benzodiazepines (BZDs), β-blockers, butyrophenones, carbamazepine, dexmedetomidine, gabapentin, propofol, and valproic acid. [13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31] The primary goals of pharmacologic management of AWS are to minimize symptom severity and prevent major complications. 6,7 The ideal agent should be cross-tolerant with alcohol.…”

Section: Introductionmentioning

confidence: 99%

“…14,37 Adjunctive agents or alternatives to BZDs may reduce these effects. [13][14][15] Phenobarbital (PHB) has been studied for patients across the continuum of AWS over the last 40 years and offers potential advantages to BZDs. [17][18][19][20][21][22][23][24][25][26][27][28][29][30][31] PHB exerts its effects in as few as 5 minutes with parenteral administration.…”

Section: Introductionmentioning

confidence: 99%

Patient Outcomes Associated With Phenobarbital Use With or Without Benzodiazepines for Alcohol Withdrawal Syndrome: A Systematic Review

et al. 2017

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Benzodiazepines are the drug of choice for alcohol withdrawal syndrome (AWS); however, phenobarbital is an alternative agent used with or without concomitant benzodiazepine therapy. In this systematic review, we evaluate patient outcomes with phenobarbital for AWS. Medline, Cochrane Library, and Scopus were searched from 1950 through February 2017 for controlled trials and observational studies using ["phenobarbital" or "barbiturate"] and ["alcohol withdrawal" or "delirium tremens."] Risk of bias was assessed using tools recommended by National Heart, Lung, and Blood Institute. From 294 nonduplicative articles, 4 controlled trials and 5 observational studies (n = 720) for AWS of any severity were included. Studies were of good quality (n = 2), fair (n = 4), and poor (n = 3). In 6 studies describing phenobarbital without concomitant benzodiazepine therapy, phenobarbital decreased AWS symptoms ( < .00001) and displayed similar rates of treatment failure versus comparator therapies (38% vs 29%). A study with 2 cohorts showed similar rates of intensive care unit (ICU) admission (phenobarbital: 16% and 9% vs benzodiazepine: 14%) and hospital length of stay (phenobarbital: 5.85 and 5.30 days vs benzodiazepine: 6.64 days). In 4 studies describing phenobarbital with concomitant benzodiazepine therapy, phenobarbital groups had similar ICU admission rates (8% vs 25%), decreased mechanical ventilation (21.9% vs 47.3%), decreased benzodiazepine requirements by 50% to 90%, and similar ICU and hospital lengths of stay and AWS symptom resolution versus comparator groups. Adverse effects with phenobarbital, including dizziness and drowsiness, rarely occurred. Phenobarbital, with or without concomitant benzodiazepines, may provide similar or improved outcomes when compared with alternative therapies, including benzodiazepines alone.

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“…Several studies have shown it to be beneficial as an adjuvant medication, specifically reducing the short-term benzodiazepine requirement and providing sedation without causing respiratory depression. [78][79][80] Dexmedetomidine can, however, lead to bradycardia and hypotension. Additionally, given its lack of action at GABA receptors, it does not target the underlying mechanism of alcohol withdrawal and as such, does not treat DTs, alcohol withdrawal seizures, or prevent the progression of AWS.…”

mentioning

confidence: 99%

“…Additionally, given its lack of action at GABA receptors, it does not target the underlying mechanism of alcohol withdrawal and as such, does not treat DTs, alcohol withdrawal seizures, or prevent the progression of AWS. 79 Finally, several small studies have examined the use of baclofen, a pure GABA B agonist. 81,82 However, a recent Cochrane review found that there is insufficient evidence to make a judgement regarding the efficacy and safety of baclofen for AWS; further research will be important to support its use.…”

mentioning

confidence: 99%

<p>Management of Alcohol Withdrawal in the Emergency Department: Current Perspectives</p>

Wolf

Curry

Nacht

et al. 2020

OAEM

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Alcohol withdrawal syndrome (AWS) is a common, heterogenous, and lifethreatening complication of alcohol use disorder (AUD). AUD is a leading cause of worldwide mortality, and many patients with AUD will develop AWS during their ED course. This review summarizes the epidemiology, pathology, and management of AWS and AUD in the emergency setting. The time course of AWS and its impact on ED treatment is emphasized. Once AWS is diagnosed, symptom-triggered benzodiazepine administration remains the most commonly provided treatment but may not be appropriate for patients with significant medical or psychiatric comorbidity or pending discharge. In these cases, ED clinicians may consider short courses of barbiturates or alternative regimens based on novel anticonvulsants. Specific treatment protocols are enumerated for clinical practice. Finally, emergency providers must not only manage acute patients' AWS but also lay the foundation for successful treatment of AUD. An approach to the disposition of the patient with AUD is presented. The authors examine shortcomings in the extant literature and suggest opportunities for further study.

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Review of adjunctive dexmedetomidine in the management of severe acute alcohol withdrawal syndrome

Cited by 16 publications

References 40 publications

Adding an orange to the banana bag: vitamin C deficiency is common in alcohol use disorders

Adding an orange to the banana bag: vitamin C deficiency is common in alcohol use disorders

Patient Outcomes Associated With Phenobarbital Use With or Without Benzodiazepines for Alcohol Withdrawal Syndrome: A Systematic Review

<p>Management of Alcohol Withdrawal in the Emergency Department: Current Perspectives</p>

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