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Should benzodiazepines always be first choice in Alcohol Withdrawal

Three Part Question

In [Adult patients with withdrawal symptoms] is[Chlordiazepoxide better than chlormethiazole] at [treating withdrawal symptoms]?

Clinical Scenario

A patient arrives in the emergency department is suffering from withdrawal symptoms. You know benzodiazepines can be given but are not sure if its the best treatment choice

Search Strategy

Using the OVID interface:
Medline 1996 to June week 3 2007:
[chlordiazepoxide.mp. or exp Chlordiazepoxide or benzodiazepines.mp. or exp Benzodiazepines or chlormethiazole.mp. or exp Chlormethiazole] and [exp Alcohol Withdrawal Seizures or withdrawal.mp. or exp Alcohol Withdrawal Delirium/ or exp Substance Withdrawal Syndrome] and [ethanol.mp. or exp Ethanol or alcoholic.mp or exp Alcoholic Intoxication/ or exp Alcoholic Beverages or alcohol abuse.mp. or Alcoholism and limit to (humans and english language)
Embase 1996 to 2007 week 26:
[chlordiazepoxide.mp or exp Chlordiazepoxide or benzodiazepines.mp. or exp Benzodiazepines] AND [chlormethiazole.mp. or exp Chlormethiazole] and [exp Alcohol Withdrawal Seizures or withdrawal.mp. or exp Alcohol Withdrawal Delirium/ or exp Substance Withdrawal Syndrome] and limit to (humans and english language)
Cochrane Database of Systematic Reviews 2nd Quarter 2007:
[chlordiazepoxide.mp. or exp Chlordiazepoxide or benzodiazepines.mp. or exp Benzodiazepines or chlormethiazole.mp. or exp Chlormethiazole] and [exp Alcohol Withdrawal Seizures or withdrawal.mp. or exp Alcohol Withdrawal Delirium/ or exp Substance Withdrawal Syndrome] and [ethanol.mp. or exp Ethanol or alcoholic.mp or exp Alcoholic Intoxication/ or exp Alcoholic Beverages or alcohol abuse.mp. or Alcoholism and limit to (humans and english language)

Search Outcome

Medline found 153 papers, Embase found 155 papers, Cochrane found 8 papers. 4 of these papers were relevant

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Berglund M et al
2002
Sweden
Eighty-two RCTS were found mainly comparing Benzodiazepine effectiveness in Patients who presented to hospitals or health care centres.Systematic Reviewthe effect of pharmacotherapy on withdrawal symptomsBenzodiazepines said to be effective, Chlormethiazole said to be effective in delerium tremensLimited studies available for chlormethiazole. Little data shown from studies analysed
Williams D and McBride JA
1998
United Kingdom
14 randomised double blinded placebo control trials and 22 double blinded comparison control trialsSystematic ReviewOutcomes were measured using scales2 trials showed chlormethiazole and chlordiazepoxide had equal efficacy in comparison to placeboDifferent scales used to measure outcome
Ntais C et al
2005
United Kingdom
57 trials with a total of 4,051 people were included.Systematic ReviewStatus of patients with regards to withdrawal symptomsBenzodiazepines were better than placebo but of varying efficacy with regards to other drugsLarge variety of outcomes and rating scales makes synthesis difficult
Lucht M et al
2002
Germany
Specialist hospital for addictive disorders. 127 caucasian german patients with alcohol dependence according to ICD 10 criteria. Assigned to 1 of 4 treatment options depending on breath alcohol concentration.Open label studyAlcohol Withdrawal Scoretiapride and carbamazepine are as effective as chlormethiazole and diazepam in intoxicated patientsLack of blinding

Comment(s)

There have been many studies comparing mainly the benzodiazepines to placebo or other drugs. The benzodiazepines have also been shown to deal well with alcohol related seizures

Clinical Bottom Line

Benzodiazepines or Chlormethiazole can be given but there is more evidence availble to support administering a benzodiazepine.

References

  1. Berglund M et al Treatment of alcohol abuse an evidence based review Alcoholism: Clinical and Experimental Research October 2003; Vol.27, No.10, pp.1645-1656
  2. Williams D and McBride JA The drug treatment of alcohol withdrawal symptoms: A systematic review Alcohol & Alcoholism 1998; Vol.33, No.2, pp. 103-115.
  3. Ntais C et al Benzodiazepines for Alcohol Withdrawal Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD005063
  4. Lucht M et al Alcohol Withdrawal Treatment in Intoxicated vs Non Intoxicated Patients: A controlled Open Label study with Tiapride/Carbamazepine, Clomethiazole and Diazepam Alcohol & Alcoholism 2003; Vol. 38, No. 2, pp.168-175