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Î Recommendation VI.15: Patients receiving repeated high intravenous
doses of lorazepam or diazepam should be monitored closely for signs
of hyponatremia and metabolic acidosis.
Î Recommendation VI.16: When treating alcohol withdrawal delirium,
use an established dosing protocol as a guide but individualize dosing
regimens based on patient's signs and symptoms. It is appropriate
for patients with alcohol withdrawal delirium to receive intravenous
symptom-triggered or fixed-dose front loading. Once light somnolence
is achieved and patients are calm and cooperative, if on IV medication,
shifting to oral symptom-triggered treatment is recommended.
Î Recommendation VI.17: Very large doses of benzodiazepines may be
needed to control agitation in alcohol withdrawal delirium, including
doses that are much higher than typically seen in other patient
populations. Clinicians should not hesitate to provide such large doses
to patients to control agitation but should keep in mind the possible
risk of over-sedation and respiratory depression. Moreover, when
large doses are used, there is risk of accumulation of long-acting
benzodiazepine metabolites, especially in patients with impaired
hepatic function or the elderly, and patients should be monitored
closely.
Î Recommendation VI.18: For patients who have been delirious longer
than 72 hours, assess for drug-induced delirium and withdrawal from
another GABAergic agent (such as gabapentin or carisoprodol). When
necessary, adjust the benzodiazepine dose.
Î Recommendation VI.19: Barbiturates can be considered an
alternative option to benzodiazepines for the treatment of alcohol
withdrawal delirium, but they are not preferred over benzodiazepines.
Phenobarbital can be used as an adjunct to benzodiazepines in
settings with close monitoring when alcohol withdrawal delirium is not
adequately controlled by benzodiazepine therapy alone.
Î Recommendation VI.20: Antipsychotic agents can be used as an
adjunct to benzodiazepines when alcohol withdrawal delirium and
hallucinations are not adequately controlled by benzodiazepine
therapy alone. They are not recommended as monotherapy for alcohol
withdrawal delirium.
Î Recommendation VI.21: Alpha2-adrenergic agonists, beta-adrenergic
antagonists and paraldehyde should not be used to treat alcohol
withdrawal delirium.
