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Qu L, Ma XP, Simayi A, Wang XL, Xu GP. Comparative efficacy of various pharmacologic treatments for alcohol withdrawal syndrome: a systematic review and network meta-analysis. Int Clin Psychopharmacol 2024; 39:148-162. [PMID: 38170803 DOI: 10.1097/yic.0000000000000526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
This study was to compare multiple classes of medications and medication combinations to find alternatives or additives for patients not applicable to benzodiazepines (BZDs). We performed a network meta-analysis to assess the comparative effect of 11 pharmacologic treatments in patients with alcohol withdrawal syndrome. Forty-one studies were included, comprising a total sample size of 4187 participants. The pooled results from the randomized controlled trials showed that there was no significant difference in the Clinical Institute Withdrawal Assessment-Alcohol, revised (CIWA-Ar) reduction with other medications or medication combinations compared to BZDs. Compared to BZDs, the mean difference in ICU length of stay of anticonvulsants + BZDs was -1.71 days (95% CI = -2.82, -0.59). Efficacy rankings from cohort studies showed that anticonvulsant + BZDs were superior to other treatments in reducing CIWA-Ar scores and reducing the length of stay in the ICU. Synthesis results from randomized controlled trials indicate that there are currently no data suggesting that other medications or medication combinations can fully replace BZDs. However, synthetic results from observational studies have shown that BZDs are effective in the context of adjuvant anticonvulsant therapy, particularly with early use of gabapentin in combination with BZDs in the treatment of alcohol withdrawal syndrome, which represents a promising treatment option.
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Affiliation(s)
- Li Qu
- Department of Anesthesia, People's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang, China
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Gabapentin to treat acute alcohol withdrawal in hospitalized patients: A systematic review and meta-analysis. Drug Alcohol Depend 2022; 241:109671. [PMID: 36402053 DOI: 10.1016/j.drugalcdep.2022.109671] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 10/13/2022] [Accepted: 10/18/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Gabapentin is an antiepileptic medication with evidence of benefit in alcohol use disorder patients. The mechanism of action of gabapentin may also benefit patients suffering from acute alcohol withdrawal syndrome (AWS). METHODS A systematic review and meta-analysis were conducted to examine if gabapentin can effectively replace/reduce the use of benzodiazepines for the treatment of acute alcohol withdrawal symptoms in hospitalized patients. Time to alcohol withdrawal symptom resolution, amount of benzodiazepines administered, rate of resolution of alcohol withdrawal symptoms, serious withdrawal-related complications, and hospital length of stay (LOS) were examined. RESULTS Eight retrospective studies (n = 2030) were included in this meta-analysis. There were no studies that examined study outcomes for patients who received only gabapentin and no benzodiazepines; in all studies, gabapentin-treated patients may have received benzodiazepines prior to gabapentin. There were no significant differences between gabapentin-treated and benzodiazepine-treated groups in time to symptom resolution, amount benzodiazepines administered, withdrawal-related complications, or LOS. There was a significant difference in the rate of symptom resolution favoring gabapentin-treated patients (p = 0.05); however, this analysis included only one study. Subgroup analyses of severe AWS patients revealed a significant decrease in LOS (p = 0.04) and a decrease in amount of benzodiazepines administered (p = 0.02) in gabapentin-treated patients, but these analyses included only one study. Subgroup analysis of patients receiving only gabapentin without benzodiazepines found a significantly decreased LOS in the gabapentin group compared to the benzodiazepine group (p < 0.001), but this analysis included only two studies. CONCLUSIONS There is insufficient evidence to support the widespread use of gabapentin to treat inpatients suffering AWS. All studies included in this meta-analysis are retrospective with high risk of confounding. Well-designed, randomized, controlled studies of gabapentin to treat patients with AWS are required.
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Cheng YC, Huang YC, Huang WL. Gabapentinoids for treatment of alcohol use disorder: A systematic review and meta-analysis. Hum Psychopharmacol 2020; 35:1-11. [PMID: 32667088 DOI: 10.1002/hup.2751] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 05/18/2020] [Accepted: 06/08/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Gabapentin (GBP) and pregabalin (PGB) have been used to treat alcohol use disorder (AUD) and alcohol withdrawal, but with inconsistent results. In this meta-analysis, we explored the effects of GBP/PGB treatment on AUD and their effects on withdrawal, craving, depression, and sleep disturbance in AUD patients. METHODS We carried out a systematic review and meta-analysis of randomized controlled trials comparing the effects of GBP/PGB on AUD with those of a placebo or control treatment. Electronic databases were searched for relevant articles published before September 2019. The primary outcome was defined as the efficacy measure on achieving abstinence or reducing alcohol consumption in a hierarchical order. We included 16 studies in our meta-analysis. RESULTS Overall, GBP had no significant benefit comparing to placebo or control treatment (Hedges' g = 0.0725, p = 0.6743). For specific alcohol-related outcome, GBP had significant effect on percentage of heavy drink (Hedges' g = 0.5478, p = 0.0441) and alcohol withdrawal symptoms (Hedges' g = 0.2475, p = 0.0425). GBP/PGB did not have significant beneficial effect on craving, depressive symptoms, or sleep disturbance. Instability was shown in sensitivity analyses of some above results. CONCLUSIONS GBP may be helpful to reduce AUD patients' heavy drinking behavior and withdrawal, but more studies are needed for drawing conclusions.
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Affiliation(s)
- Ying-Chih Cheng
- Department of Psychiatry, Taoyuan Psychiatric Centre, Ministry of Health and Welfare, Taoyuan City, Taiwan, ROC.,Department of Public Health and Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan, ROC.,Research Centre of Big Data and Meta-Analysis, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan, ROC
| | - Yu-Chen Huang
- Research Centre of Big Data and Meta-Analysis, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan, ROC.,Department of Dermatology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan, ROC.,Department of Dermatology, School of Medicine and College of Medicine, Taipei Medical University, Taipei, Taiwan, ROC
| | - Wei-Lieh Huang
- Department of Psychiatry, National Taiwan University Hospital Yunlin Branch, Douliu City, Taiwan, ROC.,Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan, ROC.,Department of Psychiatry, College of Medicine, National Taiwan University, Taipei, Taiwan, ROC.,Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan, ROC
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Bates RE, Leung JG, Morgan RJ, Fischer KM, Philbrick KL, Kung S. Retrospective Analysis of Gabapentin for Alcohol Withdrawal in the Hospital Setting: The Mayo Clinic Experience. Mayo Clin Proc Innov Qual Outcomes 2020; 4:542-549. [PMID: 33083703 PMCID: PMC7560568 DOI: 10.1016/j.mayocpiqo.2020.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objective To evaluate the efficacy and safety of a fixed-dose gabapentin taper protocol for alcohol withdrawal in hospitalized patients. Patients and Methods We retrospectively identified patients admitted to the hospital from January 1, 2016, to April 30, 2018, for alcohol withdrawal syndrome. Based on the treatment that patients received, they were divided into the gabapentin, benzodiazepine, and combination treatment groups. The primary outcome was length of stay, defined as time from admission to either discharge or 36 hours with Clinical Institute Withdrawal Assessment (CIWA) score less than 10. Inverse probability of treatment weight was used to account for differences in baseline characteristics between groups. Results A total of 443 patients met criteria for inclusion (128, 253, and 62 patients in the gabapentin, benzodiazepine, and combination groups, respectively). Baseline characteristics were similar among all groups. The median gabapentin group length of stay was 4.0 hours shorter than the benzodiazepine group (P=.012). Maximum CIWA score was 2.2 points lower in the gabapentin group (P=.003). No statistical differences were noted among safety outcomes, including incidence of seizure, intensive care unit transfer, or delirium tremens. Results were not statistically altered by inverse probability of treatment weight analysis. Conclusion A fixed-dose gabapentin taper protocol appears to be an effective and safe alternative to CIWA-driven benzodiazepines in patients hospitalized with alcohol withdrawal syndrome, though further research is necessary to define the potential subpopulations that benefit most.
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Key Words
- AUD, alcohol use disorder
- AWS, alcohol withdrawal syndrome
- CIWA, Clinical Institute Withdrawal Assessment
- GABA, γ-aminobutyric acid
- ICU, intensive care unit
- IPTW, inverse probability of treatment weight
- LOS, length of stay
- Q, quartile
- max, maximum
- min, minimum
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Affiliation(s)
- Ruth E Bates
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN
| | | | - Robert J Morgan
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN
| | - Karen M Fischer
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | | | - Simon Kung
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN
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Alcohol Withdrawal Syndrome in Neurocritical Care Unit: Assessment and Treatment Challenges. Neurocrit Care 2020; 34:593-607. [PMID: 32794143 DOI: 10.1007/s12028-020-01061-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 07/21/2020] [Indexed: 12/11/2022]
Abstract
Alcohol withdrawal syndrome (AWS) can range from mild jittery movements, nausea, sweating to more severe symptoms such as seizure and death. Severe AWS can worsen cognitive function, increase hospital length of stay, and in-hospital mortality and morbidity. Due to a lack of reliable history of present illness in many patients with neurological injury as well as similarities in clinical presentation of AWS and some commonly encountered neurological syndromes, the true incidence of AWS in neurocritical care patients remains unknown. This review discusses challenges in the assessment and treatment of AWS in patients with neurological injury, including the utility of different scoring systems such as the Clinical Institute Withdrawal Assessment and the Minnesota Detoxification Scale as well as the reliability of admission alcohol levels in predicting AWS. Treatment strategies such as symptom-based versus fixed dose benzodiazepine therapy and alternative agents such as baclofen, carbamazepine, dexmedetomidine, gabapentin, phenobarbital, ketamine, propofol, and valproic acid are also discussed. Finally, a treatment algorithm considering the neurocritical care patient is proposed to help guide therapy in this setting.
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Glahn A, Proskynitopoulos PJ, Bleich S, Hillemacher T. Pharmacotherapeutic management of acute alcohol withdrawal syndrome in critically Ill patients. Expert Opin Pharmacother 2020; 21:1083-1092. [PMID: 32281894 DOI: 10.1080/14656566.2020.1746271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Alcohol withdrawal syndrome is a common and life-threatening condition in patients suffering from alcohol use disorder. Treatment of this syndrome is challenging, especially in patients that are critically ill, either because of withdrawal symptoms or underlying conditions. For the treatment, several pharmacological agents exist, such as benzodiazepines, barbiturates, or dexmedetomidine. Nonetheless, as alcohol withdrawal syndromes can occur in every clinical setting, it is necessary to provide a guideline for clinicians confronted with this syndrome in varying clinical contexts. AREAS COVERED The authors provide a systematic review of the literature found in PubMed and Embase following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. EXPERT OPINION For the treatment of alcohol withdrawal syndrome, medications targeting the GABA system are preferred. Benzodiazepines are regarded as the gold standard. However, as many adjunct therapeutic options exist, it is essential to find symptom-triggered approaches and treatment protocols for the variety of clinical contexts. Apart from that, it is necessary to compare protocols toward clinical variables rather than investigating medications that are in use for the treatment of alcohol withdrawal syndrome.
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Affiliation(s)
- A Glahn
- Department of Psychiatry, Psychotherapy and Social Psychiatry, Hannover Medical School , Hannover, Germany
| | - P J Proskynitopoulos
- Department of Psychiatry, Psychotherapy and Social Psychiatry, Hannover Medical School , Hannover, Germany
| | - S Bleich
- Department of Psychiatry, Psychotherapy and Social Psychiatry, Hannover Medical School , Hannover, Germany
| | - T Hillemacher
- Department of Psychiatry, Psychotherapy and Social Psychiatry, Hannover Medical School , Hannover, Germany.,Department of Psychiatry and Psychotherapy, Paracelcus Medical University , Nuremberg, Germany
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