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Current Practice Patterns in the Management Of Alcohol Withdrawal Syndrome

25 There have been no publications surveying practice patterns in the management of AWS in the United States since the last national survey conducted by Saitz and colleagues in 1995. 26 Given that substantial variability exists in recommendations for managing AWS, including assessment tools and treatment regimens, the present survey aimed to evaluate current practice patterns surrounding the inpatient management of AWS in the Northeast region of the United States. A multicenter survey of inpatient pharmacological management strategies for alcohol withdrawal conducted in 104 acute-care hospitals in the United Kingdom observed that only 60% of these hospitals had a formalized protocol in place. 27 Furthermore, the existing protocols had wide variability in recommendations for vitamin dosing, duration addction treatment of treatment, fixed versus symptom-triggered dosing, and sedative medication of choice. The results of the survey prompted its authors to conclude that there is an urgent need to standardize care in the United Kingdom. Similarly, the findings from our survey will be valuable in demonstrating a potential need for establishing a standard of care for AWS treatment. For the treatment of mild or moderate AWS, most respondent hospitals utilized guidelines or protocols ( Figure 1). In addition, BZD-only regimens were the most commonly used in both mild and moderate AWS scenarios, and lorazepam was the first agent of choice ( Figure 2). In contrast, this report suggested a lack of consensus on treatment strategies for severe and BZD-refractory AWS. When a patient with severe AWS Private Alcohol Rehab In Kentucky was treated in the intermediate care unit, which was shown on the survey as a severe case scenario, 74 of the respondents reported using a BZD-based regimen with other agents as needed, but there was considerable variation in selecting other non-BZD agents, including haloperidol (51%), clonidine (23%), phenobarbital (19.3%), and valproic acid (9%) ( Figure 3). When treating a patient with BZD-refractory AWS in ICU settings, much more variety existed regarding the treatment regimens utilized. 5 This was partly because only 33% of hospitals used standardized protocols or guidelines for the treatment of BZD-refractory AWS. In this survey, a patient consistently showing a high severity of AWS despite a treatment with at least 35 mg of lorazepam over the first three hours was presented as an example of a BZD-refractory AWS case. Of 60 institutions where such patients were treated, 53 respondents reported that they would use other non-BZD agents with or without BZDs. Phenobarbital was the first agent of choice when a non–BZD-based regimen was chosen ( Figure 4), whereas dexmedetomidine or propofol was most frequently used in combination with BZDs ( There are several limitations to our survey. The primary limitation is a relatively low response rate (18%), but the investigators examined whether survey respondents (n = 90) were representative of eligible institutions (n = 504) by comparing key hospital characteristics of the two groups. Although the number of respondents from four states—Rhode Island, New Hampshire, Maine, and Vermont—was three or fewer, the investigators believe that, overall, the findings from this study are representative of all the hospitals surveyed. In addition, in the present survey, hospitals located only in the Northeast region were surveyed due to limited research resources. This survey, however, provides preliminary data for future nationwide surveys. Another limitation is that all respondents were pharmacists, not prescribers. Nonetheless, the investigators believe that it is valid to use pharmacists as a representative sample for this survey because hospital pharmacists are not only well informed of treatment protocol but also actively involved in its development and implementation.

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