PHARMACOLOGICAL MANAGEMENT OF ALCOHOL-WITHDRAWAL - A METAANALYSIS ANDEVIDENCE-BASED PRACTICE GUIDELINE

Objective.-To provide an evidence-based practice guideline on the phar macological management of alcohol withdrawal. Data Sources.-English-la nguage articles published before July 1, 1995, identified through MEDL INE search on ''substance withdrawal-ethyl alcohol'' and review of ref erences from identified articles. Study Selection.-Articles with origi nal data on human subjects. Data Abstraction.-Structured review to det ermine study design, sample size, interventions used, and outcomes of withdrawal severity, delirium, seizures, completion of withdrawal, ent ry into rehabilitation, adverse effects, and costs. Data from prospect ive controlled trials with methodologically sound end points correspon ding to the Diagnostic and Statistical Manual of Mental Disorders, Fou rth Edition, were abstracted by 2 independent reviewers and underwent meta-analysis. Data Synthesis.-Benzodiazepines reduce withdrawal sever ity, reduce incidence of delirium (-4.9 cases per 100 patients; 95% co nfidence interval, -9.0 to -0.7; P=.04), and reduce seizures (-7.7 sei zures per 100 patients; 95% confidence interval, -12.0 to -3.5; P=.003 ). Individualizing therapy with withdrawal scales results in administr ation of significantly less medication and shorter treatment (P<.001). beta-Blockers, clonidine, and carbamazepine ameliorate withdrawal sev erity, but evidence is inadequate to determine their effect on deliriu m and seizures. Phenothiazines ameliorate withdrawal but are less effe ctive than benzodiazepines in reducing delirium (P=.002) or seizures ( P<.001). Conclusions.-Benzodiazepines are suitable agents for alcohol withdrawal, with choice among different agents guided by duration of a ction, rapidity of onset, and cost. Dosage should be individualized, b ased on withdrawal severity measured by withdrawal scales, comorbid il lness, and history of withdrawal seizures. beta-Blockers, clonidine, c arbamazepine, and neuroleptics may be used as adjunctive therapy but a re not recommended as monotherapy.