LAS VEGAS – Alpha-2 agonists and a handful of other agents work at least as well as benzodiazepines for alcohol withdrawal, and they’re safer, according to Dr. José R. Maldonado. That’s why he advises against using benzodiazepines to treat alcohol withdrawal.
The risks of benzodiazepines include delirium, confusion, and respiratory depression. In addition, patients are more likely to go back to drinking if they undergo detox with benzodiazepines rather than a medication from another drug class, said Dr. Maldonado of the department of psychiatry and behavioral sciences at Stanford (Calif.) University.
Dr. Jose Maldonado
And perhaps most significantly, chronic alcohol abuse downregulates the receptors targeted by benzodiazepines, which means that people can still go into withdrawal despite the use of these drugs.
Meanwhile, numerous studies show that other agents, including valproic acid, gabapentin, carbamazepine, and alpha-2 blockers like clonidine, are just as effective. "Any of those alone will work," he said. Because of these data, Dr. Maldonado no longer prescribes benzodiazepines, he said at the annual psychopharmacology update held by the Nevada Psychiatric Association.
Instead, Dr. Maldonado and his colleagues use a nonbenzodiazepine withdrawal protocol based on the alpha-2 agonist clonidine because alpha-2 blockers address the norepinephrine overload that drives 85% of the withdrawal symptoms, including cardiac troubles, nausea, vomiting, and tremors. The drugs "slow the release of excess norepinephrine," he said. In one of many studies supporting the point, 80% (12) of 15 surgical patients treated prophylactically with diazepam went into alcohol withdrawal, and 13% (2) had delirium tremens; 10% (3) of 30 treated with clonidine went into withdrawal, and none had delirium tremens (Anesth. Analg. 2004;98:738-44).
For prophylaxis, "we slap 0.1-mg clonidine [patches on each arm]," give patients three doses of 0.1 mg clonidine orally 8 hours apart to hold them over until the patches take full effect, "then load [them] with gabapentin. That’s it. We have had zero patients progress to alcohol withdrawal." The gabapentin is used as a backup. "Our protocol combines treatments so you have a double or triple safety net," Dr. Maldonado said, noting that the combination should be safe for patients with hepatic impairment.
Active withdrawal is treated similarly, with the addition of valproic acid if needed. The rescue protocol combines the intravenous alpha-2 agonist dexmedetomidine with valproic acid. Treatment in all cases lasts at least a week and is stepped down as appropriate.
Time and again, Dr. Maldonado said he has come across patients in active withdrawal despite benzodiazepine treatment. He puts them on the new protocol and stops the benzodiazepines.
Lorazepam is held in reserve in all three scenarios, but so far has not been needed. Benzodiazepines might be useful, however, in acute situations to buy time while the other medications are assembled.
Dr. Maldonado said he had no relevant financial disclosures.