Medication

Benzodiazepines, having fewer complications than neuroleptics, are recommended as the primary medication in managing alcohol withdrawal delirium, reducing mortality, and duration of delirium. Controlled studies about the most effective benzodiazepine or route of administration are lacking. However, the following points should guide treatment: 

• Rapidly acting benzodiazepines should be used. Oral diazepam acts rapidly (within 1 hour) and is easy to administer in most treatment settings. Intravenous diazepam can also be used where agitation must be quickly controlled, without the need for an intravenous infusion. Intramuscular diazepam is poorly absorbed and not recommended. 
• Long-acting benzodiazepines (such as diazepam) provide long duration of symptom relief with minimal breakthrough symptoms. Short-acting benzodiazepines require an intravenous infusion, and should only be used in hospital settings with the capacity for close monitoring (such as ICU, high dependency unit). 
• Short-acting benzodiazepines (such as midazolam, lorazepam, oxazepam) should be used where clinicians are concerned about prolonged sedation, such as in the elderly recent head injury, liver failure, or other serious medical illness. 

From the above, it is recommended that: 

• The aim of medication is to achieve and maintain light sedation (somnolence) in which the patient is awake but tends to fall asleep unless stimulated, or is asleep and is easily roused. 
• Doses and regimens must be individually titrated for each patient, as there is considerable variation in medication needs. 
• Benzodiazepines are the first line of treatment, as described above. High doses are typically required often over 100mg diazepam or equivalent. 
• Antipsychotic medications should be used as second-line medication in controlling agitation of alcohol withdrawal, as an adjunct to (not instead of) adequate benzodiazepine doses. Controlled trials demonstrating the superiority of different antipsychotic medications are lacking; practitioners should use medications with which they are most familiar. The newer antipsychotic agents (such as risperidone, olanzapine, quetiapine) have a better safety profile (see above). 
• Dexmedetomidine is increasingly used for delirium tremens not responding to benzodiazepines in the intensive care unit setting and has been shown to reduce the requirement for intubation following sedation to control delirium.