SEATTLE — Hospitalized patients with alcohol withdrawal syndrome (AWS) —which is not uncommon—often have increased intensive care unit (ICU) and hospital lengths of stay, more hospital-acquired infections or sepsis and higher in-hospital mortality.
A report in Mayo Clinic Proceedings pointed out that treatment with benzodiazepines (BZDs) improves AWS but also can lead to complications in hospitalized patients. Side effects can include somnolence, respiratory depression, delirium and death, while, overall, greater BZD exposure associated with increased risk of adverse outcomes.1
Researchers from the University of Washington and the VA Puget Sound Healthcare System pointed out that AWS treatment with BZDs usually involves one of three dosing strategies: fixed-dose, symptom-triggered, or front-loading. Clinical guidelines generally recommend treatment of mild to moderate AWS using symptom-triggered dosing of long-acting BZDs, while front-loading with large/frequent doses of BZDs is often recommended for severe AWS.
The study team sought to describe initial benzodiazepine dosing strategies and factors associated with variation in benzodiazepine dosing in AWS patients treated at the VA.The cross-sectional study included adult patients with AWS treated with benzodiazepines at 93 VHA hospitals in 2013.
Researchers categorized treatment by initial benzodiazepine dosing strategy—fixed-dose, symptom-triggered or front-loading. They also assessed associations with patient characteristics, facility, and cumulative benzodiazepine exposure, intensive care and intubation.
The study advised that, among 6,938 medical inpatients with AWS, 2,909 (41.9%), 2829 (40.8%) and 1,200 (17.3%) received treatment with symptom-triggered, fixed-dose and front-loading benzodiazepines, respectively.
“The magnitude of differences in initial treatment associated with patient characteristics was small compared with differences associated with the predominant practice at a facility,” researchers wrote. On the other hand, they noted that, compared with fixed-dose therapy, symptom-triggered therapy was associated with higher cumulative benzodiazepine exposure (mean, 208-mg vs 182-mg diazepam equivalents) and higher probability of intensive care and intubation (28.2% vs. 21.3% and 4.8% vs. 3.5%, respectively).
“This study revealed that real-world AWS treatment of medical inpatients was often inconsistent with published guidelines recommending symptom-triggered long-acting benzodiazepines for AWS,” researchers concluded. “The facility where a patient was hospitalized was associated with marked treatment variation. In contrast to prior randomized controlled trials conducted in specialized detoxification units, hospitalized patients who received symptom-triggered therapy in this study had greater cumulative benzodiazepine exposure and higher probability of intensive care and intubation than those receiving fixed-dose therapy.”
- Steel TL, Malte CA, Bradley KA, Hawkins EJ. Benzodiazepine Treatment and Hospital Course of Medical Inpatients With Alcohol Withdrawal Syndrome in the Veterans Health Administration. Mayo Clin Proc Innov Qual Outcomes. 2022 Feb 15;6(2):126-136. doi: 10.1016/j.mayocpiqo.2021.11.010. PMID: 35224452; PMCID: PMC8855212.
