Should benzodiazepines always be first choice in Alcohol Withdrawal
Date First Published:
June 28, 2007
Last Updated:
July 6, 2007
Report by:
Neal Larkman, Medical Student (Manchester Royal Infirmary)
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:
Search Details:
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)
[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)
Outcome:
Medline found 153 papers, Embase found 155 papers, Cochrane found 8 papers. 4 of these papers were relevant
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Treatment of alcohol abuse an evidence based review 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 Review | the effect of pharmacotherapy on withdrawal symptoms | Benzodiazepines said to be effective, Chlormethiazole said to be effective in delerium tremens | Limited studies available for chlormethiazole. Little data shown from studies analysed |
| The drug treatment of alcohol withdrawal symptoms: A systematic review Williams D and McBride JA 1998 United Kingdom | 14 randomised double blinded placebo control trials and 22 double blinded comparison control trials | Systematic Review | Outcomes were measured using scales | 2 trials showed chlormethiazole and chlordiazepoxide had equal efficacy in comparison to placebo | Different scales used to measure outcome |
| Benzodiazepines for Alcohol Withdrawal Ntais C et al 2005 United Kingdom | 57 trials with a total of 4,051 people were included. | Systematic Review | Status of patients with regards to withdrawal symptoms | Benzodiazepines were better than placebo but of varying efficacy with regards to other drugs | Large variety of outcomes and rating scales makes synthesis difficult |
| Alcohol Withdrawal Treatment in Intoxicated vs Non Intoxicated Patients: A controlled Open Label study with Tiapride/Carbamazepine, Clomethiazole and Diazepam 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 study | Alcohol Withdrawal Score | tiapride and carbamazepine are as effective as chlormethiazole and diazepam in intoxicated patients | Lack of blinding |
Author Commentary:
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
Bottom Line:
Benzodiazepines or Chlormethiazole can be given but there is more evidence availble to support administering a benzodiazepine.
References:
- Berglund M et al. Treatment of alcohol abuse an evidence based review
- Williams D and McBride JA. The drug treatment of alcohol withdrawal symptoms: A systematic review
- Ntais C et al. Benzodiazepines for Alcohol Withdrawal
- Lucht M et al. Alcohol Withdrawal Treatment in Intoxicated vs Non Intoxicated Patients: A controlled Open Label study with Tiapride/Carbamazepine, Clomethiazole and Diazepam