Pharmacotherapeutic management of acute alcohol withdrawal syndrome in critically Ill patients

ABSTRACT

Introduction

Alcohol withdrawal syndrome is a common and life-threatening condition in patients suffering from alcohol use disorder. Treatment of this syndrome is challenging, especially in patients that are critically ill, either because of withdrawal symptoms or underlying conditions. For the treatment, several pharmacological agents exist, such as benzodiazepines, barbiturates, or dexmedetomidine. Nonetheless, as alcohol withdrawal syndromes can occur in every clinical setting, it is necessary to provide a guideline for clinicians confronted with this syndrome in varying clinical contexts.

Areas covered

The authors provide a systematic review of the literature found in PubMed and Embase following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.

Expert opinion

For the treatment of alcohol withdrawal syndrome, medications targeting the GABA system are preferred. Benzodiazepines are regarded as the gold standard. However, as many adjunct therapeutic options exist, it is essential to find symptom-triggered approaches and treatment protocols for the variety of clinical contexts. Apart from that, it is necessary to compare protocols toward clinical variables rather than investigating medications that are in use for the treatment of alcohol withdrawal syndrome.

KEYWORDS:

• Alcohol withdrawal syndrome
• psychopharmacotherapy
• alcohol use disorder
• critically Ill

Article highlights

• Pharmacological treatment of AWS is of high importance as AWS can be considered a generally life-threatening condition, particularly in critically ill patients

• The use of benzodiazepines is the first-line therapy for the treatment of AWS, also in patients considered critically ill

• Medications most frequently used for the treatment of AWS are those targeting the neural GABA-system

• Adjunct therapeutic agents such as barbiturates like propofol and phenobarbital, ketamine or the selective alpha-2-agonist dexmedetomidine can reduce benzodiazepine dosages and are promising options in those patients suffering from comorbid disease

• A symptom-triggered approach and pharmacological treatment protocols are promising means to improve clinical management.

This box summarizes key points contained in the article.

Declaration of interest

Thomas Hillemacher has received honoraria from Lundbeck, Otsuka, Bristol-Myers Squibb, Amomed, Janssen Pharmaceuticals and Squire. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Notes on contributors

A. Glahn

A. Glahn, MD, attending in the Department of Psychiatry, Psychotherapy and Social Psychiatry at the Hannover Medical School

P. J. Proskynitopoulos

P. J. Proskynitopoulos, B.Sc. (Psychology), medical student enrolled at Hannover Medical School

S. Bleich

S. Bleich, MD and Professor, Chief of Service of the Department of Psychiatry, Psychotherapy and Social Psychiatry at the Hannover Medical School

T. Hillemacher

T. Hillemacher, MD and Professor, Chief of Service of the Department of Psychiatry and Psychotherapy at the Paracelcus Medical University