Review: sedative-hypnotic agents reduce mortality and duration of delirium in the alcohol withdrawal syndrome.

and commentary also appear in ACP Journal Club. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . For correspondence: Dr M F Mayo-Smith, Veterans Administration Medical Center, Manchester, NH, USA. [email protected] Sources of funding: American Society of Addiction Medicine and Stepping Stones Foundation. Commentary A lcohol withdrawal delirium is a serious illness with several therapeutic options. Clinical practice suggests that the importance of alcohol withdrawal delirium may be under-recognised, thus delaying effective treatment, which should be rapid and closely monitored. While oral medication is adequate for patients with minor symptoms of alcohol withdrawal, an intravenous route must be seriously considered for delirium, because these patients are often unable to swallow, and indeed are in extremis. Although benzodiazepines are first line treatment, questions remain about specific drug selection, dosage, and administration route. For instance, do high initial doses shorten delirium more than lower doses? The review by Mayo-Smith et al shows that doses should be repeated and reassessed every few minutes. A set endpoint is necessary, as defined by ‘‘light somnolence.’’ Clinicians should consider a well monitored care setting for these patients and entertain a broad differential diagnosis, as well as examine for concurrent medical illness. Further research questions on alcohol withdrawal delirium include the use of such ancillary medications as magnesium, thiamine, and multivitamin supplements. As this review shows, the evidence for magnesium administration has not been adequately assessed. Similarly, the evidence for thiamine replacement is weak. Considering that thiamine is cheap, it is not unreasonable to provide it, although the required doses and frequencies to prevent the Wernicke-Korsakoff syndrome are unknown. Finally, the use of intravenous multivitamin supplements in the face of probable nutritional deficiency in alcoholic persons remains controversial. Little evidence exists to support the use of this medication via the intravenous route, which is considerably more expensive than the equivalent tablet. Christopher M B Fernandes, MD McMaster University/Hamilton Health Sciences Hamilton, Ontario, Canada 1 Ferguson JA, Suelzer CJ, Eckert GJ, et al. Risk factors for delirium tremens development. J Gen Intern Med 1996;11:410–4. 2 Day E, Bentham P, Callaghan R, et al. Thiamine for Wernicke-Korsakoff Syndrome in people at risk from alcohol abuse. Cochrane Database Syst Rev 2004;(1):CD004033. THERAPEUTICS 17 EBM Volume 10 February 2005 ebm.bmjjournals.com group.bmj.com on April 7, 2017 Published by http://ebm.bmj.com/ Downloaded from