Therapies for Alcohol Withdrawal Syndrome (AWS)
According to the 2023 National Survey on Drug Use and Health (NSDUH), nearly 29 million people ages 12 and older had Alcohol Use Disorder in the previous year. As emergency medicine clinicians, we treat many of these individuals for alcohol withdrawal syndrome (AWS) during our shifts. While benzodiazepines have long been the mainstay of treatment for AWS, there are several other effective AWS interventions that can be used to treat a range of patient presentations – and a few new potential therapies on the horizon.
Gabapentin
Gabapentin, traditionally used for neuropathic pain and seizures, has emerged as a valuable tool in our AWS arsenal. Recent studies have shown that gabapentin can effectively manage mild to moderate withdrawal symptoms while having a more favorable side effect profile compared to benzodiazepines. A 2019 randomized controlled trial published in JAMA Internal Medicine demonstrated that gabapentin not only reduced the need for benzodiazepines but also improved drinking outcomes in the weeks following discharge.
Key benefits of gabapentin include:
- Lower risk of respiratory depression
- Reduced potential for abuse
- Efficacy in treating common comorbidities like insomnia and anxiety
Phenobarbital
According to Open Access Emergency Medicine, barbiturates like phenobarbital, either alone or in combination with benzodiazepines, offer alternative approaches to AWS treatment. Neurology, Toxicology and Medications highlights the safety and effectiveness of use of phenobarbital as the first-line monotherapy for patients in severe (and often refractory) alcohol withdrawal in the ED. In addition, many studies show the combination of barbiturates and benzodiazepines to be an effective AWS treatment.
Advantages of phenobarbital include:
- Extended duration of action, potentially reducing recurrent symptoms and return ED visits
- Lower risk of respiratory depression compared to equivalent doses of benzodiazepines
- Effectiveness in benzodiazepine-resistant AWS
Potential Treatments on the Horizon
Dexmedetomidine
Dexmedetomidine is alpha 2 agonist that can be used as an adjunctive therapy to reduce AWS symptoms like tremors, hypertension and tachycardia. An Annals of Emergency Medicine study highlights the benefits of dexmedetomidine including:
- Reduced benzodiazepine/barbiturate requirements
- Shorter ICU length of stay
- Improved sedation
Because of an increased risk of cardiovascular complications, the authors of the study cite dexmedetomidine as a potential therapy for patients with ongoing sympathetic symptoms who require higher doses of benzodiazepines or barbiturates.
Ketamine
Ketamine, a sedative agent, is a promising adjunct treatment for benzodiazepine-resistant AWS because of its rapid onset, minimal respiratory effects at low doses, and analgesic properties. A Critical Care Medicine study highlights lower likelihood of intubation, shorter ICU stays and decreased need for additional infusions as key benefits of ketamine infusion for patients with delirium tremens. More research needed to determine optimal use of ketamine in the ED but its potential is encouraging.
Conclusion
While benzodiazepines remain the cornerstone of AWS management, additional interventions offer exciting alternatives and adjuncts that may improve outcomes and patient safety. By staying informed of newer and emerging therapies and judiciously incorporating them into our practice, we can enhance outcomes, improve safety, and potentially reduce complications and return visits for patients with AWS.
Responses