Management of Alcohol Withdrawal | 10.16.2018

There is not much that is controversial about the management of withdrawal from long-term use of ethanol. As with other classes of drugs, generally, it is a matter of replacing like with like. But a particular focus of addiction medicine training, and a source of anxiety to all who staff consultation-liaison services, psychiatric or medical, is the management of alcohol withdrawal that appears poorly-responsive or even unresponsive to benzodiazepine (BZ) use.The authors of this embedded abstract have assigned an acronym, RAW, Resistant Alcohol Withdrawal; it might equally have been called "Runaway Alcohol Withdrawal,” for those familiar with the clinical presentation.  Once falling behind on the administration of a sedative-hypnotic, it is the very devil to catch up.The task is made more difficult by complications associated with the BZ preparations. Ethylene glycol derivatives, such as that used as a diluent for I.V. lorazepam, can actually reach toxic levels.The occasional failure to suppress withdrawal symptoms may reflect the narrow spectrum of receptor activity of BZs, when compared to ethanol; or it may have its source in another mechanism. But no one disputes the desirability of better predictive factors, that will allow anticipatory medication.The authors identify 5 in particular:

• Thrombocytopenia doubles likelihood of benzodiazepine-resistant alcohol withdrawal.
• (A) patient with psychiatric history (is) 2 times more likely to be benzodiazepine resistant.
• (A) 1-unit increase (in) comorbidity or severity illness decreases benzodiazepine resistance [counter-intuitive – WFH].
• Benzodiazepine-resistance (is) associated with abnormal admission liver enzymes.
• Caucasian race and male gender (are)more predictive of benzodiazepine resistance.

Benedict NJ, et al., Predictors of resistant alcohol withdrawal (RAW): A retrospective case-control study.

Drug Alcohol Depend. 2018 Oct 2;192:303-308. doi: 10.1016/j.drugalcdep.2018.08.017. [Epub ahead of print]

https://www.drugandalcoholdependence.com/article/S0376-8716(18)30649-5/fulltext

- W. Haning, MD