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PHARMACOLOGICAL MANAGEMENT OF ALCOHOL WITHDRAWAL:
A Meta-Analysis and Evidence-Based Practice Guideline
ABSTRACT:
Objective: To provide an evidence-based practice guideline on the pharmacological management of alcohol withdrawal.
Data Sources: English-language articles published before July 1995 identified through MEDLINE search on "substance withdrawal - ethyl alcohol" and review of references from identified articles.
Study Selection: Articles with original data on human subjects.
Data Abstraction: Structured review to determine study design, sample size, interventions used and outcomes of withdrawal severity, delirium, seizures, completion of withdrawal, entry into rehabilitation, adverse effects and costs. Data from prospective controlled trials with methodologically sound endpoints corresponding to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition were abstracted by two independent reviewers and underwent meta-analysis.
Data Synthesis: Benzodiazepines reduce withdrawal severity, reduce incidence of delirium (-4.9 cases/100 patients, 95%CI-9.0, -0.7, p=0.04) and reduce seizures (-7.7 seizures/100 patients, 95%CI-12.0, -3.5, p=0.003). Individualizing therapy with withdrawal scales results in administration of significantly less medication and shorter treatment (p <0.001). Beta-blockers, clonidine and carbamazepine ameliorate withdrawal severity but inadequate evidence is inadequate to determine their effect on delirium and seizures. Phenothiazines ameliorate withdrawal but are less effective than benzodiazepines in reducing delirium (p=0.002) or seizures (p=0.000003).
Conclusions: Benzodiazepines are suitable agents for alcohol withdrawal, with choice among different agents guided by duration of action, rapidity of onset and cost. Dosage should be individualized, based on withdrawal severity measured by withdrawal scales, comorbid illness and history of withdrawal seizures. Beta-blockers, clonidine, carbamazepine and neuroleptics may be used as adjunctive therapy but are not recommended as monotherapy.
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