Clonidine as early adjunctive therapy for alcohol withdrawal in the emergency department

Lindsey Shannon, Christopher Leong, Ahmed Assem Mahmoud

Abstract


Alpha-2-agonists may decrease cumulative benzodiazepines (BZD) requirements in alcohol withdrawal syndrome (AWS), leading to a reduction in BZD related adverse events. This study aimed to evaluate the impact of adjunctive clonidine on BZD requirements in patients with AWS who presented to the emergency department (ED). A retrospective chart review study from 1/2015 to 12/2016 was performed in patients who were admitted for AWS via the ED and would have received at least 24 hours of benzodiazepines. The primary study outcome was the difference of the 12-hour cumulative BZD requirements in lorazepam equivalents (BZD-LE) in patients who received clonidine compared to patients who received BZD monotherapy. Secondary endpoints included total hospital benzodiazepine requirements, intensive care unit (ICU) admission, ICU and hospital length of stay, and incidence of hypotension. A total of 11 patients who received clonidine adjunctive therapy and 33 patients to standard management were included in the study. The median 12 hour cumulative BZD-LE was 16 mg (IQR 3-19) in the intervention group compared to 7 mg (IQR 4-13) in the control group (P = 0.90). However, the total cumulative BZD-LE requirements for the hospital stay was 31 mg (IQR 21-48) in the intervention group compared to 45 mg (IQR 26-71) in the control group (P = 0.28). In conclusion, adjunctive clonidine administration to BZD in AWS initiated in the ED was not associated with a decrease in 12 hour BZD requirements.


Keywords


Pharmacy

Full Text:

PDF

References


Long D, Long B, Koyfman A. The emergency medicine management of severe alcohol withdrawal. Am J Emerg Med 35:1005-1011, 2017.

Jesse S, Brathen G, Ferrara M, et al. Alcohol withdrawal syndrome: Mechanisms, manifestations, and management. Acta Neurol Scand 135:4-16, 2017.

Kosten TR, O’Connor PG. Management of drug and alcohol withdrawal. N Engl J Med 348:1786-1795, 2003.

Schuckit MA. Alcohol-use disorders. The Lancet 373:492-501, 2009.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders [Internet]. Arlington, Virginia, USA, p. 991, 2013.

Barr J, Zomorodi K, Bertaccini EJ, Shafer SL, Geller E. A double-blind, randomized comparison of i.v. lorazepam versus midazolam for sedation of ICU patients via a pharmacologic model. Anesthesiology 95:286-298, 2001.

Chouinard G. Issues in the clinical use of benzodiazepines: Potency, withdrawal, and rebound. J Clin Psychiatry 65:7-12, 2004.

Valenzuela CF. Alcohol and neurotransmitter interactions. Alcohol Health Res World 21:144-148, 1997.

Fitzgerald PJ. Elevated norepinephrine may be a unifying etiological factor in the abuse of a broad range of substances: Alcohol, nicotine, marijuana, heroin, cocaine, and caffeine. Subst Abuse 13:171-183, 2013.

Linnoila M, Mefford I, Nutt D, Adinoff B. Alcohol withdrawal and noradrenergic function. Ann Intern Med 107:875-889, 1987.

Turner RC, , Lichstein PR, Peden JG Jr, Busher JT WL. Alcohol withdrawal syndromes: a review of pathophysiology, clinical presentation, and treatment. J Gen Intern Med 4:432-44, 1989.

Isbell H, Fraser HF, Wikler A, Belleville RE, Eisenman AI. An experimental study of the etiology of rum fits and delirium tremens. Q J Stud Alcohol 16:1-33, 1955.

Mihic SJ, Ye Q, Wick MJ, Koltchine V, Krasowski MD, Finn SE, et al. Sites of alcohol and volatile anaesthetic action on GABA(A) and glycine receptors. Nature 389:385-859, 1997.

Mayo-Smith MF, Beecher LH, Fischer TL, Gorelick D a., Guillaume JL, Hill A, et al. Management of alcohol withdrawal delirium. An evidence-based practice guideline. Arch Intern Med 164:1405-12, 2004.

Amato L, Minozzi S, Vecchi S, Davoli M. Benzodiazepines for alcohol withdrawal. Amato Laura Minozzi Silvia Vecchi Simona Davoli Mar alcohol withdrawal. Cochrane Database Syst Rev 3:CD005063, 2010.

Björkqvist SE. Clonidine in alcohol withdrawal. Acta Psychiatr Scand 52:256-263, 1975.

Eyer F, Schreckenberg M, Hecht D, Adorjan K, Schuster T, Felgenhauer N, et al. Carbamazepine and valproate as adjuncts in the treatment of alcohol withdrawal syndrome: a retrospective cohort study. Alcohol Alcohol 46:177-184, 2011.

Linn DD, Loeser KC. Dexmedetomidine for Alcohol Withdrawal Syndrome. Ann Pharmacother 49: 1336-1342, 2015.

Muzyk AJ, Fowler J a, Norwood DK, Chilipko A. Role of α2-agonists in the treatment of acute alcohol withdrawal. Ann Pharmacother 45:649-657, 2011.

A. C, O.P. R, S. CC, S. CC. A comparative study of efficacy & tolerability of Lorazepam and Gabapentin in the treatment of alcohol withdrawal syndrome. Int J Pharm Sci Rev Res 3:80-84, 2010.

Kaim SC, Klett CJ RB. Treatment of the acute alcohol withdrawal state: a comparison of four drugs. Am J Psychiatry 125:1640-1646, 1969.

VanderWeide LA, Foster CJ, MacLaren R, Kiser TH, Fish DN, Mueller SW. Evaluation of Early Dexmedetomidine Addition to the Standard of Care for Severe Alcohol Withdrawal in the ICU. J Intensive Care Med 31:198-204, 2016.

Frazee EN, Personett HA, Leung JG, Nelson S, Dierkhising RA, Bauer PR. Influence of dexmedetomidine therapy on the management of severe alcohol withdrawal syndrome in critically ill patients. J Crit Care 29:298-302, 2014.

Walinder J, Balldin J, Bokstrom K, Karlsson I, Lundstrom B, Svensson TH. Clonidine suppression of the alcohol withdrawal syndrome. Drug Alcohol Depend 8:345-348, 1981.

Manhem P, Nilsson LH, Moberg A ‐L, Wadstein J, Hbkfelt B. Alcohol Withdrawal: Effects of clonidine treatment on sympathetic activity, the renin-aldosterone system, and clinical symptoms. Alcohol Clin Exp Res 9:238-2343, 1985.

Robinson BJ, Robinson GM, Maling TJ JR. Is clonidine useful in the treatment of alcohol withdrawal? Alcohol Clin Exp Res 13:95-98, 1989.

Baumgartner GR, Rowen RC. Clonidine vs chlordiazepoxide in the management of acute alcohol withdrawal syndrome. Arch Intern Med 147:1223-1226, 1987.

Mueller SW, Preslaski CR, Kiser TH, Fish DN, Lavelle JC, Malkoski SP, et al. A randomized, double-blind, placebo-controlled dose range study of dexmedetomidine as adjunctive therapy for alcohol withdrawal. Crit Care Med 42:1131-1139, 2014.

Adinoff B. Double-blind study of alprazolam, diazepam, clonidine, and placebo in the alcohol withdrawal syndrome: preliminary findings. Alcohol Clin Exp Res 18:873-878, 1994.


Refbacks

  • There are currently no refbacks.