Symptom-triggered Therapy Research Articles

Symptom triggered therapy in delirium tremens

Alcohol withdrawal due to inadvertent abstinence in alcohol dependent patients is a significant problem. These patients frequently suffer from severe withdrawal or delirium tremens, which requires intensive management. Delirium tremens has a mortality rate of 1-5 % [1]. Prevention of alcohol withdrawal syndrome has been shown to improve morbidity and mortality and shorten hospital stay [2]. Benzodiazepines have been shown to be safe and effective for preventing or treating seizures and delirium and are the preferred agents for treating alcohol withdrawal syndrome [1, 3]. A symptom-triggered approach to dosing benzodiazepenes may have significant advantages over a fixed schedule therapeutic approach. These include the ability to individualise treatment, reduction in treatment duration and reduced occurrence of delirium tremens [1, 4]. Previous studies have shown equally efficacious results with a symptom triggered approach [5]. There is, however, a requirement of suitably trained staff [1]. We report a case of alcohol dependence, which was admitted to the medical ward for dyspepsia but progressed to develop florid delirium tremens. He was initially managed with standard fixed schedule therapy but when this proved ineffective, he was switched to symptom-triggered therapy. An intensive care approach with continuous monitoring and timely use of therapeutic interventions lead to a successful outcome in a potentially life threatening situation.

How is alcohol withdrawal syndrome best managed in the emergency department?

Alcohol abuse is a major cause of morbidity and mortality and subsequently presents a substantial burden on the NHS. Whether presentations are directly or indirectly linked, the emergency department (ED) holds a predominant role in dealing with this matter. Alcohol withdrawal syndrome is a common complication of alcohol misuse. Given its pathophysiology and manifestation of symptoms, early recognition and treatment is paramount in preventing a medical emergency. From a review of the associated literature, a standardised protocol for its management in ED is consequently advocated. This includes: Identification of those at risk via routine screening; Monitoring progression and severity using an alcohol withdrawal scale; Implementation of symptom-triggered therapy on the basis of objective evidence collected. Nonetheless, further studies are required to aid the choice of tools and ascertain the efficacy of such protocols within the ED department. Due to time constraints of this real-world setting, feasibility may be considered as important as reliability and validity if new practices are to be considered.

Implementation of a Symptom-Triggered Benzodiazepine Protocol for Alcohol Withdrawal in Family Medicine Inpatients

Purpose The purpose of this pilot study was to review the implementation of symptom-triggered benzodiazepine therapy and evaluate the feasibility and outcomes as compared with a previous hospital standard of fixed-dose phenobarbital protocol for alcohol withdrawal on a family medicine service. Methods This retrospective chart review of 46 patients' medical records was performed on admissions to the family medicine service occurring between February and October of 2005 compared with February and October of 2006. Included in the study were adults who were suffering from alcohol withdrawal symptoms (AWS), who admitted to heavy daily alcohol intake, who were intoxicated on admission, and who had a history of AWS and/or history of AWS-related seizures. The Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA-Ar) was used to evaluate the impact of individualized symptom-triggered therapy on outcome measurements utilizing symptom-triggered benzodiazepine therapy compared with the previous hospital standard using a fixed-dose phenobarbital protocol. Results One hundred percent of the patients in the phenobarbital group required drug compared with 38% in the benzodiazepine group ( P < 0.001). Fewer patients (9.5%) in the benzodiazepine group left the hospital against medical advice (AMA), while 36% of patients in the phenobarbital group left AMA ( P = 0.045). There was no significant difference in length of stay or the number of days on the protocol. Conclusion The results of the pilot study demonstrated that symptom-triggered therapy using benzodiazepines resulted in better outcomes than fixed-dosing phenobarbital. Importantly, most patients in the benzodiazepine group required no drug administration.

Poor Care, Not Poor Protocols, for Alcohol Withdrawal–Reply–I

Poor Care, Not Poor Protocols, for Alcohol Withdrawal–Reply–I

Poor Care, Not Poor Protocols, for Alcohol Withdrawal–4

Poor Care, Not Poor Protocols, for Alcohol Withdrawal–4

Inappropriate Use of Symptom-Triggered Therapy for Alcohol Withdrawal in the General Hospital

To determine if hospitalized medical and surgical patients were placed inappropriately on symptom-triggered therapy (STT) for alcohol withdrawal syndrome (AWS) and if certain conditions were more likely to be associated with inappropriate STT use or adverse events. We randomly selected 124 (25%) of the 495 Mayo Clinic inpatients who received STT according to the Revised Clinical Institute for Withdrawal Assessment for Alcohol (CIWA-Ar) protocol in 2003 and assessed them for STT appropriateness, defined as having both intact verbal communication and recent alcohol use. Adverse events, including delirium tremens, seizures, or death, were correlated with CIWA-Ar appropriateness. Of the 124 randomly selected patients, only 60 (48%) met both inclusion criteria. Of the remaining 64 patients, 9 (14%) were drinkers but could not communicate, and 35 (55%) could communicate but had not been drinking. Twenty (31%) met neither criterion. Univariate analysis identified a significant association between inappropriate initiation and chronic heart failure, postoperative status (POS), liver disease (LD), nonmetastatic cancer, and chemical dependency consultation. On multivariate analysis, only LD (P equals .02) and POS (P equals .01) retained significance, with LD more and POS less likely to predict appropriateness. Seven of 11 patients who experienced adverse events had received STT according to the CIWA-Ar protocol (P equals .05). Univariate analysis identified a significant association between adverse events and a history of alcohol dependence or AWS. Multivariate analysis showed significance only for a history of alcohol dependence (P equals .049). Fewer than half of the randomly selected patients met both of the inclusion criteria for the CIWA-Ar instrument, leading us to conclude that more stringent evaluation is needed. Particularly postoperatively, alternative explanations for putative AWS should be sought. Health care professionals should more aggressively seek information on recent alcohol use from medical records, family members, and patients themselves.

Alcohol Withdrawal Requiring Massive Prolonged Benzodiazepine Infusion

The objective of this case report is to describe a patient with prolonged alcohol withdrawal requiring massive standing doses of benzodiazepines. The setting is the medical intensive care unit of the Tripler Army Medical Center, Honolulu, Hawaii. The patient is a 58-year-old alcohol-dependent male presenting with mental status changes and agitation following an uncomplicated cystoprostatectomy, who ultimately required massive doses of benzodiazepines to treat his symptoms effectively. We conclude that symptom-triggered therapy proved ineffective in this case due to inability to achieve adequate frequency of assessments. Ultimately, a lengthy, high-dose, fixed interval benzodiazepine regimen was required. The 5-week period of intensive care illustrated that scheduled doses of benzodiazepines may be required and massive and prolonged doses are sometimes necessary. Adherence to a slow-weaning protocol understood by an interdisciplinary team was critical to this patient's recovery. Additionally, toxicity from the high-dose medication was not observed.

Symptom-Triggered versus Standard Chlormethiazole Treatment of Inpatient Alcohol Withdrawal: Clinical Implications from a Chart Analysis

To evaluate clinical effectiveness and safety of 2 different detoxification treatment protocols, a chart analysis of hospital inpatients consecutively admitted for alcohol withdrawal during one year was undertaken. Records of 33 patients receiving symptom-triggered treatment (using a modified version of the revised Clinical Institute Withdrawal Assessment for Alcohol Scale) were compared with those of patients treated by applying a fixed-dose regimen (n = 32). Patients (45.3 ± 9.8 years, 21% female) of both groups were comparable regarding illness severity, epidemiologic parameters as well as complications during the observed treatment period. Under symptom-triggered therapy, chlormethiazole (CMZ) treatment duration (4.2 ± 3.5 vs. 7.5 ± 3.3 days, Mann-Whitney U test: p = 0.0003) and cumulative CMZ dosage (4,352 ± 4,589 vs. 9,921 ± 6,599 mg, Mann-Whitney U test: p = 0.0004) were significantly reduced. The daily CMZ dose was significantly lower at days 1–5 in the group receiving symptom-triggered treatment. There was no influence of age on the outcome parameters of either treatment group. In conclusion, an individualized symptom-triggered treatment of alcohol withdrawal with CMZ seems to be equally safe but more efficient than a scheduled regimen.

Symptom-Triggered Therapy for Alcohol Withdrawal

Dosing benzodiazepines for alcohol withdrawal syndrome (AWS) based on frequent assessment of symptoms can decrease duration of treatment and amount of

Symptom-Triggered Therapy for Alcohol Withdrawal Syndrome in Medical Inpatients

To assess the efficacy of symptom-triggered therapy vs usual care for alcohol withdrawal syndrome (AWS) in medical inpatients. This study was a retrospective analysis of patients admitted to general medical services between January 1, 1995, and December 31, 1998, who experienced AWS during the admission. This study was conducted at Saint Marys Hospital, Rochester, Minn. Patients were identified from hospital discharge diagnoses and pharmacy data. Symptom-triggered therapy for AWS was initiated in 1997. Patients were divided into preimplementation (1995-1996) and postimplementation (1997-1998) cohorts. Age, sex, medical comorbid conditions, previous AWS (including seizures and delirium tremens), duration of treatment for AWS, benzodiazepine use and dose, complications of AWS, and adverse outcomes of treatment during the incident admission were abstracted from the medical records of eligible patients. Comorbid conditions were classified according to the Charlson comorbidity index. Differences between the cohorts were assessed with use of logistic regression models and analysis of covariance. Review of medical records from 638 admissions (536 patients) yielded 216 admissions eligible for this study. After adjustment for age, sex, Charlson comorbidity index, previous AWS, previous alcohol withdrawal seizures, and previous delirium tremens, we found no significant difference between cohorts for duration of treatment (P=.16), benzodiazepine use (P=.21), total dose of benzodiazepine (P=.38), or total complication rate (P=.053). We did observe a significant difference in the occurrence of delirium tremens between the 2 treatment groups (P=.04). This was especially apparent for patients with no history of delirium tremens. Symptom-triggered therapy is effective treatment for AWS in medical inpatients. In this retrospective study, it did not result in shorter duration of treatment but was associated with a decreased occurrence of delirium tremens, the most severe and life-threatening complication of AWS. This result was most apparent in patients with no history of delirium tremens.

Benzodiazepine treatment for alcohol-dependent patients.

Benzodiazepines (BZDs) are the preferred pharmacological agents for treatment of acute alcohol withdrawal. Treatment with BZDs can be administered on an out-patient basis for subjects experiencing mild to moderate withdrawal and on an in-patient basis for the most severe forms of withdrawal. The efficacy of BZDs for long-term treatment of alcoholism has been more controversial. Controlled studies indicate that BZD treatment does not improve abstinence rate. Most reviews of drug treatment of alcoholism conclude that routine use of BZDs is not indicated on a long-term basis. However, the clinical reality is that many alcoholics are treated by BZDs during detoxification and then continue to receive them for the treatment of anxiety disorders or insomnia, often secondary to alcohol dependence. After a review of the biological properties of BZDs related to their therapeutic issues, this review discusses the major indications for BZD treatment of alcoholism. BZDs are first prescribed to prevent and treat symptoms of alcohol withdrawal. Indication of BZD administration during alcohol withdrawal and criteria of choice of an agent according to its half-life or its route of administration are discussed. The different protocols of BZD treatment during withdrawal are considered (e.g. loading techniques, symptom-triggered therapy). The use of BZDs in the treatment of anxiety associated with alcohol dependence is examined. Among unwanted effects, risk of abuse, memory impairment, confusion, and delirium are described. Finally, practical guidelines for the use of BZDs in the treatment of alcoholism are proposed.

PHARMACOTHERAPIES FOR ALCOHOL ABUSE: Withdrawal and Treatment

Pharmacologic management of alcoholism is only one part of the management of both alcohol dependence and withdrawal, which also includes the provision of a calm, quiet environment; reassurance; ongoing reassessment; attention to fluid and electrolyte disorders; treatment of coexisting addictions and common medical, surgical, and psychiatric comorbidities; and referral for ongoing psychosocial and medical treatment. For further discussion of these topics, the reader is referred to previously published sources. A survey of alcoholism treatment programs revealed that although benzodiazepines were the most commonly used drugs, standardized monitoring of patients' withdrawal severity was not common practice, and a significant minority of clinicians were using a variety of other drugs, some not known to prevent or treat the complications of withdrawal. Treatment should be based on the available evidence (Working Group on Pharmacological Management of Alcohol Withdrawal: American Society of Addiction Medicine Committee on Practice Guidelines: Pharmacological management of alcohol withdrawal: An evidence-based practice guideline. Unpublished draft, 1997). Patients with significant symptoms, patients with complications such as seizures or delirium tremens, and patients at higher risk for complications of alcohol withdrawal should receive benzodiazepines, particularly chlordiazepoxide, diazepam, or lorazepam, because of their safety and documented efficacy in preventing and treating the most serious complications of alcohol withdrawal. These drugs may be dosed on a fixed schedule for a predetermined number of doses on a tapering schedule over several days, or they may be administered by front-loading. An alternative approach for selected patients without seizures or acute comorbidity is symptom-triggered therapy, which individualizes treatment and decreases the duration and dose of medication administration. With either of the regimens, patients should have their withdrawal severity monitored until symptoms are resolving. Once withdrawal from alcohol is safely completed, the focus should turn to helping to prevent relapse. Disulfiram may be useful in highly motivated subsets of patients and when compliance-enhancing strategies are used. Naltrexone is useful in the broader population of patients entering treatment for alcohol dependence. These pharmacologic interventions should be given in the context of ongoing psychosocial support. There is substantial evidence that pharmacologic management of alcohol abuse and dependence is effective. As would be predicted from alcohol's myriad cellular effects, no panacea exists for alcoholism. For alcohol withdrawal, however, although treatment regimens have only recently been refined, evidence for effective treatment of symptoms and prevention of complications with benzodiazepines has been available for decades. Within the last decade, effective treatments, including naltrexone, have been shown to reduce alcohol intake in alcohol-dependent persons. Given the prevalence and cost of alcohol-related problems, all effective therapies (including pharmacologic treatments) should be considered to treat alcohol abuse and dependence.

Individualized Treatment for Alcohol Withdrawal. A Randomized Double-blind Controlled Trial

Objective. —To assess the effect of an individualized treatment regimen on the intensity and duration of medication treatment for alcohol withdrawal. Design. —A randomized double-blind, controlled trial. Setting. —An inpatient detoxification unit in a Veterans Affairs medical center. Patients. —One hundred one patients admitted for the treatment of alcohol withdrawal who could give informed consent and had no history of seizures or medication use that might alter the clinical course of withdrawal. Intervention. —Patients were randomized to either a standard course of chlordiazepoxide four times daily with additional medication as needed (fixed-schedule therapy) or to a treatment regimen that provided chlordiazepoxide only in response to the development of the signs and symptoms of alcohol withdrawal (symptomtriggered therapy). The need for administration of as-needed medication was determined using a validated measure of the severity of alcohol withdrawal. Main Outcome Measures. —Duration of medication treatment and total chlordiazepoxide administered. Results. —The median duration of treatment in the symptom-triggered group was 9 hours compared with 68 hours in the fixed-schedule group ( P P Conclusions. —Symptom-triggered therapy individualizes treatment, decreases both treatment duration and the amount of benzodiazepine used, and is as efficacious as standard fixed-schedule therapy for alcohol withdrawal. ( JAMA . 1994;272:519-523)

Individualized treatment of alcohol withdrawal

<h3>To the Editor.</h3> —The recent article entitled "Individualized Treatment for Alcohol Withdrawal" by Dr Saitz and colleagues¹compared "fixed-schedule therapy" (substitution) with "symptom-triggered therapy" (suppression). The conclusions are open to misinterpretation for the following reasons. The dosage chosen for the fixed schedule (400 mg of chlordiazepoxide) may be high for groups of subjects with little evidence of alcohol withdrawal (selection bias). A Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) median score of 9 is barely recognizable as alcohol withdrawal (and some subjects had scores of 0). No entry criterion for alcohol withdrawal was used (presumably it was the expectation of withdrawal). Previous studies using a predominantly white male veteran population have demonstrated that only 13% of these subjects required drug treatment.²Other general hospital studies have revealed that a median dose of 50 mg of diazepam (200 mg of chlordiazepoxide) was required using similar criteria for treatment

Individualized Treatment of Alcohol Withdrawal

To the Editor. —The recent article entitled Individualized Treatment for Alcohol by Dr Saitz and colleagues 1 compared fixed-schedule therapy (substitution) with symptom-triggered therapy (suppression). The conclusions are open to misinterpretation for the following reasons. The dosage chosen for the fixed schedule (400 mg of chlordiazepoxide) may be high for groups of subjects with little evidence of alcohol withdrawal (selection bias). A Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) median score of 9 is barely recognizable as alcohol withdrawal (and some subjects had scores of 0). No entry criterion for alcohol withdrawal was used (presumably it was the expectation of withdrawal). Previous studies using a predominantly white male veteran population have demonstrated that only 13% of these subjects required drug treatment. 2 Other general hospital studies have revealed that a median dose of 50 mg of diazepam (200 mg of chlordiazepoxide) was required using similar criteria for treatment

Individualized Treatment of Alcohol Withdrawal-Reply

In Reply. —One goal of our study was to follow up on the hypotheses generated in previous work that suggested that less medication could be used to treat alcohol withdrawal when therapy was individualized using an alcohol withdrawal severity measure. To accomplish this goal, we compared an individualized treatment strategy to a well-established, commonly used regimen. Our study showed that symptom-triggered therapy is more appropriate (shorter, less intense pharmacologic treatment and guided by the patient's symptoms) than fixed-schedule regimens for patients with alcohol dependence who abruptly cease their regular alcohol intake. Regarding generalizability, we would not extend our results to apply to those with seizures or acute coexistent illness. The alcohol withdrawal severity scales contain items that are not specific for alcohol withdrawal and that may be present for other reasons in patients with coexistent acute illness. Acute illness and seizures may also place patients at risk for more severe

Individualized Treatment for Alcohol Withdrawal

To assess the effect of an individualized treatment regimen on the intensity and duration of medication treatment for alcohol withdrawal. A randomized double-blind, controlled trial. An inpatient detoxification unit in a Veterans Affairs medical center. One hundred one patients admitted for the treatment of alcohol withdrawal who could give informed consent and had no history of seizures or medication use that might alter the clinical course of withdrawal. Patients were randomized to either a standard course of chlordiazepoxide four times daily with additional medication as needed (fixed-schedule therapy) or to a treatment regimen that provided chlordiazepoxide only in response to the development of the signs and symptoms of alcohol withdrawal (symptom-triggered therapy). The need for administration of "as-needed" medication was determined using a validated measure of the severity of alcohol withdrawal. Duration of medication treatment and total chlordiazepoxide administered. The median duration of treatment in the symptom-triggered group was 9 hours, compared with 68 hours in the fixed-schedule group (P < .001). The symptom-triggered group received 100 mg of chlordiazepoxide, and the fixed-schedule group received 425 mg (P < .001). There were no significant differences in the severity of withdrawal during treatment or in the incidence of seizures or delirium tremens. Symptom-triggered therapy individualizes treatment, decreases both treatment duration and the amount of benzodiazepine used, and is as efficacious as standard fixed-schedule therapy for alcohol withdrawal.

Individualized treatment for alcohol withdrawal. A randomized double-blind controlled trial

<h3>Objective.</h3> —To assess the effect of an individualized treatment regimen on the intensity and duration of medication treatment for alcohol withdrawal. <h3>Design.</h3> —A randomized double-blind, controlled trial. <h3>Setting.</h3> —An inpatient detoxification unit in a Veterans Affairs medical center. <h3>Patients.</h3> —One hundred one patients admitted for the treatment of alcohol withdrawal who could give informed consent and had no history of seizures or medication use that might alter the clinical course of withdrawal. <h3>Intervention.</h3> —Patients were randomized to either a standard course of chlordiazepoxide four times daily with additional medication as needed (fixed-schedule therapy) or to a treatment regimen that provided chlordiazepoxide only in response to the development of the signs and symptoms of alcohol withdrawal (symptomtriggered therapy). The need for administration of "as-needed" medication was determined using a validated measure of the severity of alcohol withdrawal. <h3>Main Outcome Measures.</h3> —Duration of medication treatment and total chlordiazepoxide administered. <h3>Results.</h3> —The median duration of treatment in the symptom-triggered group was 9 hours compared with 68 hours in the fixed-schedule group (<i>P</i>&lt;.001). The symptom-triggered group received 100 mg of chlordiazepoxide, and the fixed-schedule group received 425 mg (<i>P</i>&lt;.001). There were no significant differences in the severity of withdrawal during treatment or in the incidence of seizures or delirium tremens. <h3>Conclusions.</h3> —Symptom-triggered therapy individualizes treatment, decreases both treatment duration and the amount of benzodiazepine used, and is as efficacious as standard fixed-schedule therapy for alcohol withdrawal. (<i>JAMA</i>. 1994;272:519-523)