Research Needs for Inpatient Management of Severe Alcohol Withdrawal Syndrome: An Official American Thoracic Society Research Statement

Phenobarbital Versus Benzodiazepines for Alcohol Withdrawal in the Medical Intensive Care Unit (ICU): A Retrospective Cohort Study

Background: Phenobarbital (PHB) is a safe and efficacious alternative to benzodiazepines (BZD) for treating severe alcohol withdrawal (AWS). However, the safety of utilizing PHB for patients initially treated with BZD is unknown. Objective: To evaluate the safety and efficacy of PBH compared to BZDs in severe AWS in the medical intensive care unit (ICU). Methods: This was a retrospective cohort study comparing critically ill patients admitted for AWS who received BZDs or PHB. The primary outcome was time to persistent resolution of altered mentation. Secondary outcomes included development and duration of delirium, need for mechanical ventilation, development of withdrawal seizures, and ICU and hospital length of stay. Results: Ninety-five patients were evaluated (53 in PHB group, 42 in BZD group). Before study medication, less BZD patients demonstrated abnormal mentation compared with PHB patients (RASS < -2: 2.39% vsvs. 28.12%, respectively, and RASS > +2: 9.9% vsvs. 48.76%; P <0.001 for both). No difference was seen between groups for the primary outcome (1.8 hours for BZD cohort vsvs. 13.81 hours for PHB cohort; P =0.22). More patients in the BZD cohort developed a seizure after study medication administration (5.67% vs 0%, respectively; P =0.02). No significant difference was seen in other secondary outcomes. Conclusions: This study provides support for use of PHB after BZD if patients remain in uncontrolled withdrawal. Despite significant doses of BZDs before PHB, patients in the PHB cohort demonstrated similar clinical and safety outcomes compared to BZD alone.

Association Between GABRG2 and Self-Rating of the Effects of Alcohol in a French Young Adult Sample

Purpose

Alcohol use is a leading risk factor for preventable death, injury, and disease globally. Low sensitivity to the effects of alcohol is influenced by genes and predicts risk for harmful alcohol use and alcohol use disorder (AUD). Alcohol induces effects partly by modulation of gamma-aminobutyric acid receptors type A (GABAARs). This study investigates the relationship between genetic variation in GABAAR subunit genes and individual alcohol sensitivity among French university students.

Patients and Methods

The study involved 1,409 French university students (34.5% women; mean age 20.3 years). Alcohol sensitivity was measured by the Self-Rating of the Effects of Alcohol Scale (SRE). SRE-scores from initial drinking, regular drinking, and heavy drinking were investigated for correlations with alcohol consumption and for associations with single nucleotide polymorphisms (SNPs) in GABAAR subunit genes (GABRA2, GABRG2, GABRA6).

Results

We replicated correlations between low alcohol sensitivity and high alcohol consumption. We further found an association between the minor allele in rs211014 (GABRG2) and higher SRE-scores, linked to dizziness and motor incoordination. Genetic variation in GABRG2 has previously been associated with processes involving motor coordination (alcohol withdrawal, febrile- and epileptic seizures).

Conclusion

The results from our study suggest that genetic variation in GABRG2 may influence alcohol sensitivity, which could inform strategies for assessing risk for harmful alcohol use and AUD.

Management of alcohol withdrawal syndromes in general hospital settings

The covid-19 pandemic was associated with an unprecedented increase in alcohol consumption and associated morbidity, including hospitalizations for alcohol withdrawal. Clinicians based in hospitals must be ready to identify, assess, risk-stratify, and treat alcohol withdrawal with evidence based interventions. In this clinically focused review, we outline the epidemiology, pathophysiology, clinical manifestations, screening, assessment, and treatment of alcohol withdrawal in the general hospital population. We review and summarize studies addressing the drug treatment of alcohol withdrawal syndromes in inpatient populations, with a focus on the use of benzodiazepine drugs, phenobarbital, antiseizure drugs, and α-2 adrenergic drugs. Emerging areas of interest include the use of novel alcohol biomarkers, risk stratification instruments, alternative symptom severity scales, severe withdrawal syndromes resistant to benzodiazepine drugs, and treatment protocol variations-including non-symptom-triggered and benzodiazepine-sparing protocols. We identify key areas for research including identification of populations who will benefit from non-benzodiazepine strategies, more individualized risk stratification approaches to guide treatment, and greater inclusion of gender and racial and ethnic minorities in future studies.

Guideline concordance of electronic health record order sets for hospital-based treatment of alcohol withdrawal syndrome

BACKGROUND

Treatment of alcohol withdrawal syndrome (AWS) in hospitals is inconsistent. Electronic health record (EHR) order sets protocolize care.

OBJECTIVE

We examined variation in AWS order sets across hospital organizations and their concordance with AWS guidelines.

METHODS

We conducted a cross-sectional study of hospital organization user-created EHR order sets for AWS extracted from the December 2021 Epic® userweb community library. Hospital organizations with an acute care hospital and≥ $\ge $ 1 AWS order set were included. We measured the proportion of guideline-concordant care practices within four categories: (1) laboratory assessment, (2) risk assessment for severe AWS and associated management changes, (3) symptom assessment and treatment of AWS, and identification and management of complications and (4) screening, diagnosis, and treatment of unhealthy alcohol use and AUD including medications for alcohol use disorder (MAUD).

RESULTS

Ninety-five organizations with 289 order sets were included. The proportion of organizations with guideline-concordant laboratory assessments included testing of electrolytes (83%), hepatic function (75%), substance use (83%), and screening for infections (33%). Guidance for assessing risk of severe AWS (34%) and indications for care escalation (63%) used inconsistent definitions. Use of guideline-concordant medications for AWS (99%) and AWS symptom scores (91%) were nearly universal. MAUD was included by two organizations (2%). A common templated order set was used by 26% of organizations in EHR order sets.

CONCLUSIONS

We observed frequent organizational inclusion of guideline-concordant medications and symptom scores but rare and/or poorly defined guidance for evaluating risk of severe AWS, escalation of care, and MAUD.

Review of Attributes and Outcomes of Hospitalized Patients with Alcohol Withdrawal

Background

Alcohol abuse leads to millions of hospital admissions each year in the United States. Alcohol withdrawal syndrome (AWS) is associated with several serious complications, including seizures, delirium tremens, and death. Benzodiazepines have been the mainstay of treatment for hospitalized patients with alcohol withdrawal.

Objective

To compare hospital length of stay (LOS) among different protocols for the management of AWS in hospitalized patients.

Methods

We conducted a retrospective study of 49,125 adult patients admitted over 4 years (2018-2022) to HCA Healthcare hospitals across the USA with a diagnosis of alcohol use disorder or alcohol withdrawal. Hospital LOS was the primary outcome examined across various treatment groups (chlordiazepoxide, diazepam, gabapentin, lorazepam, phenobarbital). Secondary outcomes included the initial Clinical Institute Withdrawal Assessment (CIWA) score, intensive care unit (ICU) admission rates, readmission rates, and mortality.

Results

The average age of patients admitted was 48 years, and the majority (72%) were White males. Lorazepam was the most frequently used protocol and was associated with the lowest LOS (3.96 days). Patients treated with lorazepam had relatively higher initial CIWA scores. Only 11% of patients were admitted to the ICU during their hospitalization, and only 2% were intubated or ventilated. There were no 30-day readmissions, and less than 1% of patients admitted with a diagnosis of AWS died. Other protocols, such as gabapentin, diazepam, phenobarbital, and chlordiazepoxide, were less commonly used and had variable impacts on the outcomes studied.

Conclusions

The results of this retrospective study support lorazepam as an effective treatment for AWS management. Future research should focus on comparing the effectiveness of alcohol withdrawal assessment tools in patients with baseline psychiatric disorders.

Incidence of Hospitalizations Involving Alcohol Withdrawal Syndrome in a Primary Care Population

Importance

Alcohol withdrawal syndrome (AWS) is an important cause and complication of hospitalizations. Although common and preventable, the incidence of AWS during hospitalizations is poorly described.

Objective

To evaluate the incidence and proportional incidence of hospitalizations involving AWS in an adult primary care population overall and across patient characteristics.

Design, Setting, and Participants

This retrospective cohort study used electronic health records and insurance claims from Kaiser Permanente Washington (KPWA) between July 1, 2018, and June 30, 2022. The study included adults with 1 or more primary care visits during this period or the year prior, where primary care included annual standardized alcohol screening using the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C).

Exposures

Age, sex, race, Hispanic ethnicity, AUDIT-C scores, and comorbid diagnoses.

Main Outcome and Measures

Hospitalizations involving AWS were defined by diagnosis codes documented during hospitalizations (incidence numerator). Time enrolled in KPWA determined person-enrolled-years (incidence denominator). Proportional incidence was calculated as the incidence of hospitalizations involving AWS divided by the incidence of all-cause hospitalizations. Proportional incidence was also estimated for hospitalizations involving other common chronic conditions (chronic obstructive pulmonary disease, diabetes, heart failure, and hypertension), which were also defined using hospital diagnosis codes.

Results

Among 544 825 adults engaged in primary care (mean [SD] age, 47.0 [17.9] years; 310 069 [56.9%] female; 3656 [0.7%] American Indian or Alaska Native, 55 206 [10.1%] Asian, 25 406 [4.7%] Black, 5204 [1.0%] Native Hawaiian or Other Pacific Islander, 365 780 [67.1%] White, 19 791 [3.6%] multiracial, 15 963 [2.9%] other races, and 53 819 [9.9%] unknown race; 33 987 [6.2%] Hispanic, 414 269 [76.0%] not Hispanic, and 96 569 [17.7%] unknown ethnicity), incidence of hospitalizations involving AWS was 169 (95% CI, 159-179) per 100 000 person-enrolled-years overall but as high as 15 347 (95% CI, 13 502-17 331) in patients with other alcohol-attributable diagnoses. The proportional incidence of hospitalizations involving AWS was 2.3% overall, with variation by age, sex, and AUDIT-C scores (eg, 9%-11% in male patients aged 30-49 years and 23%-44% in patients with high-risk AUDIT-C scores of 7-12 points). In most cases, among adults younger than 60 years, proportional incidence of hospitalizations involving AWS matched or surpassed that of other common chronic conditions (chronic obstructive pulmonary disease, diabetes, heart failure, and hypertension).

Conclusions and Relevance

In this cohort study of a large primary care population served by an integrated health system, AWS hospitalizations were common, especially in male patients, younger age groups, and individuals with high-risk alcohol use. During hospitalizations, the burden of AWS was similar to or exceeded complications of other chronic diseases that receive greater medical attention.

Alcohol Withdrawal Severity Measures for Identifying Patients Requiring High-Intensity Care

OBJECTIVES

Alcohol withdrawal syndrome (AWS) may progress to require high-intensity care. Approaches to identify hospitalized patients with AWS who received higher level of care have not been previously examined. This study aimed to examine the utility of Clinical Institute Withdrawal Assessment Alcohol Revised (CIWA-Ar) for alcohol scale scores and medication doses for alcohol withdrawal management in identifying patients who received high-intensity care.

DESIGN

A multicenter observational cohort study of hospitalized adults with alcohol withdrawal.

SETTING

University of Chicago Medical Center and University of Wisconsin Hospital.

PATIENTS

Inpatient encounters between November 2008 and February 2022 with a CIWA-Ar score greater than 0 and benzodiazepine or barbiturate administered within the first 24 hours. The primary composite outcome was patients who progressed to high-intensity care (intermediate care or ICU).

INTERVENTIONS

None.

MAIN RESULTS

Among the 8742 patients included in the study, 37.5% (n = 3280) progressed to high-intensity care. The odds ratio for the composite outcome increased above 1.0 when the CIWA-Ar score was 24. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) at this threshold were 0.12 (95% CI, 0.11-0.13), 0.95 (95% CI, 0.94-0.95), 0.58 (95% CI, 0.54-0.61), and 0.64 (95% CI, 0.63-0.65), respectively. The OR increased above 1.0 at a 24-hour lorazepam milligram equivalent dose cutoff of 15 mg. The sensitivity, specificity, PPV, and NPV at this threshold were 0.16 (95% CI, 0.14-0.17), 0.96 (95% CI, 0.95-0.96), 0.68 (95% CI, 0.65-0.72), and 0.65 (95% CI, 0.64-0.66), respectively.

CONCLUSIONS

Neither CIWA-Ar scores nor medication dose cutoff points were effective measures for identifying patients with alcohol withdrawal who received high-intensity care. Research studies for examining outcomes in patients who deteriorate with AWS will require better methods for cohort identification.

Management of alcohol withdrawal syndrome in patients with alcohol-associated liver disease

Alcohol-associated liver disease is a common and severe sequela of excessive alcohol use; effective treatment requires attention to both liver disease and underlying alcohol use disorder (AUD). Alcohol withdrawal syndrome (AWS) can be dangerous, is a common barrier to AUD recovery, and may complicate inpatient admissions for liver-related complications. Hepatologists can address these comorbid conditions by learning to accurately stage alcohol-associated liver disease, identify AUD using standardized screening tools (eg, Alcohol Use Disorder Identification Test), and assess risk for and symptoms of AWS. Depending on the severity, alcohol withdrawal often merits admission to a monitored setting, where symptom-triggered administration of benzodiazepines based on standardized scoring protocols is often the most effective approach to management. For patients with severe liver disease, selection of benzodiazepines with less dependence on hepatic metabolism (eg, lorazepam) is advisable. Severe alcohol withdrawal often requires a "front-loaded" approach with higher dosing, as well as intensive monitoring. Distinguishing between alcohol withdrawal delirium and HE is important, though it can be difficult, and can be guided by differentiating clinical characteristics, including time to onset and activity level. There is little data on the use of adjuvant medications, including anticonvulsants, dexmedetomidine, or propofol, in this patient population. Beyond the treatment of AWS, inpatient admission and outpatient hepatology visits offer opportunities to engage in planning for ongoing management of AUD, including initiation of medications for AUD and referral to additional recovery supports. Hepatologists trained to identify AUD, alcohol-associated liver disease, and risk for AWS can proactively address these issues, ensuring that patients' AWS is managed safely and effectively and supporting planning for long-term recovery.

Critical care for patients with substance use disorders

PURPOSE OF REVIEW

To examine the impact of substance use disorders (SUDs) on critical illness and the role of critical care providers in treating SUDs. We discuss emerging evidence supporting hospital-based addiction treatment and highlight the clinical and research innovations needed to elevate the standards of care for patients with SUDs in the intensive care unit (ICU) amidst staggering individual and public health consequences.

RECENT FINDINGS

Despite the rapid increase of SUDs in recent years, with growing implications for critical care, dedicated studies focused on ICU patients with SUDs remain scant. Available data demonstrate SUDs are major risk factors for the development and severity of critical illness and are associated with poor outcomes. ICU patients with SUDs experience mutually reinforcing effects of substance withdrawal and pain, which amplify risks and consequences of delirium, and complicate management of comorbid conditions. Hospital-based addiction treatment can dramatically improve the health outcomes of hospitalized patients with SUDs and should begin in the ICU.

SUMMARY

SUDs have a significant impact on critical illness and post-ICU outcomes. High-quality cohort and treatment studies designed specifically for ICU patients with SUDs are needed to define best practices and improve health outcomes in this vulnerable population.

Prevalence and clinical impact of alcohol withdrawal syndrome in alcohol-associated hepatitis and the potential role of prophylaxis: a multinational, retrospective cohort study

Background

The prevalence and impact of alcohol withdrawal syndrome (AWS) in patients with alcohol-associated hepatitis (AH) are unknown. In this study, we aimed to investigate the prevalence, predictors, management, and clinical impact of AWS in patients hospitalized with AH.

Methods

A multinational, retrospective cohort study enrolling patients hospitalized with AH at 5 medical centres in Spain and in the USA was performed between January 1st, 2016 to January 31st, 2021. Data were retrospectively retrieved from electronic health records. Diagnosis of AWS was based on clinical criteria and use of sedatives to control AWS symptoms. The primary outcome was mortality. Multivariable models controlling for demographic variables and disease severity were performed to determine predictors of AWS (adjusted odds ratio [OR]) and the impact of AWS condition and management on clinical outcomes (adjusted hazard ratio [HR]).

Findings

In total, 432 patients were included. The median MELD score at admission was 21.9 (18.3-27.3). The overall prevalence of AWS was 32%. Lower platelet levels (OR = 1.61, 95% CI 1.05-2.48) and previous history of AWS (OR = 2.09, 95% CI 1.31-3.33) were associated with a higher rate of incident AWS, whereas the use of prophylaxis decreased the risk (OR = 0.58, 95% CI 0.36-0.93). The use of intravenous benzodiazepines (HR = 2.18, 95% CI 1.02-4.64) and phenobarbital (HR = 2.99, 95% CI 1.07-8.37) for AWS treatment were independently associated with a higher mortality. The development of AWS increased the rate of infections (OR = 2.24, 95% CI 1.44-3.49), the need for mechanical ventilation (OR = 2.49, 95% CI 1.38-4.49), and ICU admission (OR = 1.96, 95% CI 1.19-3.23). Finally, AWS was associated with higher 28-day (HR = 2.31, 95% CI 1.40-3.82), 90-day (HR = 1.78, 95% CI 1.18-2.69), and 180-day mortality (HR = 1.54, 95% CI 1.06-2.24).

Interpretation

AWS commonly occurs in patients hospitalized with AH and complicates the hospitalization course. Routine prophylaxis is associated with a lower prevalence of AWS. Prospective studies should determine diagnostic criteria and prophylaxis regimens for AWS management in patients with AH.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Comparative efficacy and safety of pharmacotherapies for alcohol withdrawal: a systematic review and network meta-analysis

BACKGROUND AND AIMS

There have been few head-to-head clinical trials of pharmacotherapies for alcohol withdrawal (AW). We, therefore, aimed to evaluate the comparative performance of pharmacotherapies for AW.

METHODS

Six databases were searched for randomized clinical trials through November 2021. Trials were included after a blinded review by two independent reviewers. Outcomes included incident seizures, delirium tremens, AW severity scores, adverse events, dropouts, dropouts from adverse events, length of hospital stay, use of additional medications, total benzodiazepine requirements, and death. Effect sizes were pooled using frequentist random-effects network meta-analysis models to generate summary ORs and Cohen's d standardized mean differences (SMDs).

RESULTS

Across the 149 trials, there were 10 692 participants (76% male, median 43.5 years old). AW severity spanned mild (n = 32), moderate (n = 51), and severe (n = 66). Fixed-schedule chlormethiazole (OR, 0.16; 95% CI, 0.04-0.65), fixed-schedule diazepam (OR, 0.16; 95% CI, 0.04-0.59), fixed-schedule lorazepam (OR = 0.19; 95% CI, 0.08-0.45), fixed-schedule chlordiazepoxide (OR = 0.21; 95% CI, 0.08-0.53), and divalproex (OR = 0.22; 95% CI, 0.05-0.86) were superior to placebo at reducing incident AW seizures. However, only fixed-schedule diazepam (OR, 0.19; 95% CI, 0.05-0.76) reduced incident delirium tremens. Oxcarbazepine (d = -3.69; 95% CI, -6.21 to -1.17), carbamazepine (d = -2.76; 95% CI, -4.13 to -1.40), fixed-schedule oxazepam (d = -2.55; 95% CI, -4.26 to -0.83), and γ-hydroxybutyrate (d = -1.80; 95% CI, -3.35 to -0.26) improved endpoint Clinical Institute Withdrawal Assessment for Alcohol-Revised scores over placebo. Promazine and carbamazepine were the only agents significantly associated with greater dropouts because of adverse events. The quality of evidence was downgraded because of the substantial risk of bias, heterogeneity, inconsistency, and imprecision.

CONCLUSIONS

Although some pharmacotherapeutic modalities, particularly benzodiazepines, appear to be safe and efficacious for reducing some measures of alcohol withdrawal, methodological issues and a high risk of bias prevent a consistent estimate of their comparative performance.