title: Treatment of Severe Alcohol Withdrawal.
abstract: OBJECTIVE
  Approximately 50% of patients with alcohol dependence experience alcohol withdrawal. Severe alcohol withdrawal is characterized by seizures and/or delirium tremens, often refractory to standard doses of benzodiazepines, and requires aggressive treatment. This review aims to summarize the literature pertaining to the pharmacotherapy of severe alcohol withdrawal.
  
  
  METHODS
  PubMed (January 1960 to October 2015) was searched using the search termsalcohol withdrawal, delirium tremens, intensive care, andrefractory Supplemental references were generated through review of identified literature citations.
  
  
  METHODS
  Available English language articles assessing pharmacotherapy options for adult patients with severe alcohol withdrawal were included.
  
  
  RESULTS
  A PubMed search yielded 739 articles for evaluation, of which 27 were included. The number of randomized controlled trials was limited, so many of these are retrospective analyses and case reports. Benzodiazepines remain the treatment of choice, with diazepam having the most favorable pharmacokinetic profile. Protocolized escalation of benzodiazepines as an alternative to a symptom-triggered approach may decrease the need for mechanical ventilation and intensive care unit (ICU) length of stay. Propofol is appropriate for patients refractory to benzodiazepines; however, the roles of phenobarbital, dexmedetomidine, and ketamine remain unclear.
  
  
  CONCLUSIONS
  Severe alcohol withdrawal is not clearly defined, and limited data regarding management are available. Protocolized administration of benzodiazepines, in combination with phenobarbital, may reduce the need for mechanical ventilation and lead to shorter ICU stays. Propofol is a viable alternative for patients refractory to benzodiazepines; however, the role of other agents remains unclear. Randomized, prospective studies are needed to clearly define effective treatment strategies.
authors: Spectrum Health Butterworth Hospital, Grand Rapids, MI, USA kyle.schmidt@spectrumhealth.org.
authors: Kyle J
authors: KJ
authors: Schmidt
authors: St John Hospital and Medical Center, Grosse Pointe, MI, USA.
authors: Mitesh R
authors: MR
authors: Doshi
authors: Beaumont Hospital, Royal Oak, MI, USA.
authors: Jenna M
authors: JM
authors: Holzhausen
authors: Beaumont Hospital, Royal Oak, MI, USA.
authors: Allycia
authors: A
authors: Natavio
authors: Beaumont Hospital, Royal Oak, MI, USA.
authors: Megan
authors: M
authors: Cadiz
authors: Beaumont Hospital, Royal Oak, MI, USA.
authors: Jim E
authors: JE
authors: Winegardner
mesh_terms: D000430:Alcohol Withdrawal Delirium / Q000188:drug therapy; D000437:Alcoholism / Q000188:drug therapy* / Q000503:physiopathology; D001569:Benzodiazepines / Q000627:therapeutic use; D003422:Critical Care; D020927:Dexmedetomidine / Q000627:therapeutic use; D004359:Drug Therapy, Combination; D006801:Humans; D010634:Phenobarbital / Q000627:therapeutic use; D015742:Propofol / Q000627:therapeutic use; D016032:Randomized Controlled Trials as Topic; D012121:Respiration, Artificial; D012189:Retrospective Studies; D013375:Substance Withdrawal Syndrome / Q000188:drug therapy* / Q000503:physiopathology
chemical_list: D001569:Benzodiazepines; D020927:Dexmedetomidine; D015742:Propofol; D010634:Phenobarbital
keywords: alcohol withdrawal; benzodiazepine; critical care; delirium tremens; dexmedetomidine; intensive care; phenobarbital; propofol; refractory; severe