Best Choice of Treatment for Delirium Tremens

This topic has moved to the main topic on Delirium Tremens

Clinical Vignette: Preventing Complication in A Man with Agitation

A 30-year-old man, who is a heavy alcohol drinker, presented to the emergency department with agitation, altered sensorium, marked tremors, visual hallucinations. On assessment, he is unaware of the time, place, and person. His blood pressure and pulse were 160/11 and 115/min on arrival but fluctuated on monitoring. A GP had given him haloperidol IM and diazepam IV to control his behavioral disturbance. 

What treatment-complication could arise?

a)       Seizures
b)      Over-sedation
c)       Respiratory depression
d)      Arrhythmia
e)       Worsening agitation

Benzodiazepines for the Treatment of Catatonia
Safest Treatment Option for Delirium Tremens
WHO Alcohol Withdrawal Treatment Guidelines

Common Crisis Situations in Clinical Practice

Point out the crises seen in day to day clinical practice.

1. Developmental crises common to all occur in Stressful states of human maturation and transition. e.g. hospitalization
2. Situational crises person faces stressful and traumatic event e.g. flood, earthquake, rape, etc.

WHO Guidelines for the Treatment of Alcohol Withdrawal

Zolpidem for the Treatment of Catatonia

Zolpidem, a positive allosteric modulator of gamma-aminobutyric acid receptors, seems to be a safe and effective treatment alternative. 

Benzodiazepines for the Treatment of Catatonia

Benzodiazepines are the first-choice treatment for catatonia, regardless of the underlying condition. Benzodiazepines are positive allosteric modulators of GABA-A receptors and will correct deficient GABA-ergic function in the orbitofrontal cortex.

Following a positive Lorazepam Challenge Test, repeated doses of benzodiazepines can a treatment. Their use is safe, easy, and effective, with remission rates reported to be as high as 70–80%.

About 65% Rates in a Naturalistic Study

In a naturalistic study of 66 children and adolescents with catatonia, they found that benzodiazepines improved catatonia in 65% of cases, that there was no relation between dose and level of improvement, that the dose was higher sometimes (up to 15 mg of lorazepam) than the dose recommended in pediatric patients, and that side effects were few.

Two-thirds Improved in a Trial of 107 adults

In a recent trial in 107 adult inpatients (49% with a psychotic disorder; 44% with a mood disorder), lower success rates they reported lower success rates: two-thirds responded but only one-third of patients remitted. The authors argue that a delay between illness onset and treatment could explain the lower remission rate) but the doses used in the trial (3–6 mg per day) were inadequately low. As described above, studies have repeatedly shown that chronic catatonia associated with schizophrenia is less responsive to benzodiazepines.

Beckmann and Colleagues Found them Ineffective

Beckmann and colleagues, in a 5-year follow-up study, found benzodiazepines ineffective in the treatment of chronic catatonic schizophrenia. Another study reported a comparable poor response (to lorazepam 6 mg per day); it was a randomized double-blind, placebo-controlled trial in 18 patients with chronic catatonia in schizophrenia.

Efficacy Depends on Dose

Efficacy of benzodiazepines in catatonia depends on dosage, and doses from 8 to 24 mg lorazepam per day are common and are tolerated without ensuing sedation, especially when instituted using daily incremental dosages. Most authors suggest starting at 1–2 mg of lorazepam every 4–12 h and adjusting the dose in order to relieve catatonia without sedating the patient. With an adequate dose, we usually see a response within 3–7 days, but sometimes, the response can be gradual. If we use high dosages of lorazepam, patients should be monitored carefully for excessive sedation and respiratory compromise. Whether some benzodiazepines are more efficacious in catatonia is not clear yet.

Clinicians accept lorazepam to be the first-choice drug, demonstrating a 79% remission rate and the highest frequency of use. Studies have also reported the successful use of diazepam, oxazepam, or clonazepam. There is no consensus on how long benzodiazepines to continue benzodiazepines, and we discontinue them once the underlying illness has remitted. In several cases, however, catatonic symptoms will emerge each time lorazepam is tapered off, urging the clinician to continue benzodiazepines for an extended period.

Neuroleptic malignant syndrome 

Manifestations

MNEMONIC FEVER

• Fever
• Encephalopathy
• Vitals
• Unstable
• Enzymes
• Rigidity of Muscles

Treatment

• Dantrolene
• D2 agonists (e.g., bromocriptine).