Trials comparing inpatient symptom-triggered vs fixed-dosing benzodiazepine therapy in alcohol withdrawal syndrome
| Saitz et al16 | Jaeger et al17 | Daeppen et al18 | Weaver et al19 | Reoux and Miller20 | |
|---|---|---|---|---|---|
| No. of patients | 101 | 216 | 117 | 183 | 40 |
| Type of program | Alcohol withdrawal inpatient treatment program | Retrospective, adult medicine patients | Alcohol withdrawal inpatient treatment program | Prospective, adult medicine patients | Addiction unit vs medical and psychiatric services |
| Duration and monitoring | 4 days; CIWA-Ar scores every 8 hours and 1 hour after medication dose | Up to 7 days; CIWA-Ar scores every 1–2 hours | 3 days; CIWA-Ar scores every 30 minutes | CIWA-Ar every 4 hours | 2 to 8 days; CIWA-Ar scores every 8 hours |
| Symptom-triggered protocol | If CIWA-Ar ≥ 8, chlordiazepoxide 20–100 mg every hour | If CIWA-Ar > 10, chlordiazepoxide 50–100 mg with repeated doses | Placebo every 6 hours If CIWA-Ar 8–15, oxazepam 15 mg If CIWA-Ar > 15, oxazepam 30 mg | If CIWA-Ar 6–9, lorazepam 0.5 mg intravenously or orally; If 10–19, 2 mg If 20–29, 3 mg if 30–39, 4 mg | If CIWA-Ar ≥ 10, oxazepam 30 mg or chlordiaz-epoxide 50 mg every hour until < 10 |
| Fixed schedule | Chlordiazepoxide 50 mg every 6 hours for 4 doses, then 25 mg every 6 hours for 8 doses | Usual care: tapering, fixed-dose regimen, or sporadic dosing by medical staff | Oxazepam 30 mg every 6 hours | Lorazepam 2 mg every 4 hours for 48 hours, then 1 mg every 4 hours for 24 hours, then 0.5 mg every 4 hours for 24 hours | As ordered by attending physician |
| Total dosea | 100 vs 425 mg (P < .001) | Benzodiazepine equivalents 20.1 vs 20.1 mg | 37.5 vs 231.4 mg (P < .001) | Lower with symptom-triggered protocol | Benzodiazepine equivalents 82.7 vs 367.5 mg (P < .01) |
| Duration of therapy (hours)a | 9 vs 68 (P < .001) | 44.9 vs 55.5 | 20 vs 62.7 (P < .001) | — | 10.7 vs 20.7 (P < .01) |
| CIWA-Ar score differencesa | Not significant | Not reported | P < .01 | P < .01 | Not reported |
| Outcomesa | Delirium tremens (DTs) 2% vs 6% Readmission in 30 days 6% vs 8% | DTs 6.9% vs 20.5% (P < .04) | No DTs One seizure in symptom-triggered group | No DTs or seizures in either group Median length of stay 3 days in both groups | No DTs, seizures, or adverse drug events in either group Oversedation and hypotension in one patient in usual-care group |
↵a Symptom-triggered group vs fixed-schedule group.
CIWA-Ar = revised Clinical Institute Withdrawal Assessment for Alcohol scale (Table 1)