| Accuracy | |
| Valid for practice | |
| True to literature | |
| Overall quality |
Please peer-review rate this blog post by clicking on the stars.
Sometimes a question is posed on Twitter that generates a great discussion from colleagues 'round the globe. Here is one such example.
Benzodiazepines remain the standard of treatment for ethanol withdrawal, particularly seizures and delirium tremens.Who uses precedex for their EtOH withdrawal? What's your experience been? @critcareguys @criticalcarenow @cliffreid @emcrit @pharmertoxguy— Ari Kestler (@arikestler) December 28, 2012
Alpha-2 agonists that reduce sympathetic output may be effective adjunct treatment modalities without suppressing respiratory drive. Some older studies using clonidine demonstrated possible benefit. There are also several case reports and a small case series using dexmedetomidine (a parenteral alpha-2 agonist). Three larger case series were published in 2012 evaluating dexmedetomidine in this role. FDA-approved dosing is 0.2-0.7 mcg/kg/hr as a continuous infusion. [1]
The Data
- A retrospective case series of 10 ICU patients demonstrated safety of dexmedetomidine for ethanol withdrawal. Only 3 patients needed intubation, less benzodiazepines were required, heart rate was reduced up to 10 bpm, and blood pressure was decreased up to 3 mm Hg. Maximum dexmedetomidine dose used was 1.2 mcg/kg/hr. [2]
- A prospective case series of 18 ICU patients further demonstrated safety of dexmedetomidine for ethanol withdrawal when administered for a mean 24 hours. No patients required intubation. Time to resolution of alchohol withdrawal was 3.8 days, with and ICU length of stay 7.1 days, and hospital length of stay 12.1 days. Maximum dexmedetomidine dose used was 1.5 mcg/kg/hr. [3]
- A retrospective case series of 20 ICU patients demonstrated a 62% reduction in benzodiazepine dosing after initiation of dexmedetomidine and a 21% reduction in alcohol withdrawal severity score. Only one patient required intubation. Dexmedetomidine was stopped in one patient who had two 9-second asystolic pauses noted on telemetry. [4]
Key Points
While none of these studies had a comparison group, there are a few take home points worth mentioning:
- Dexmedetomidine may be a useful adjunct to benzodiazepines for ethanol withdrawal patients (in the ED or ICU).
- Reduced benzodiazepine requirements have been observed.
- Dexmedetomidine does not suppress the respiratory drive and can be administered to non-intubated patients.
- Bradycardia and possibly hypotension are the major adverse effects with dexmedetomidine use.
Translation to Clinical Care
Some are using adjunct alpha-2 agonists with success (with benzodiazepines).
Some are using adjunct alpha-2 agonists with success (with benzodiazepines).
@arikestler @critcareguys @cliffreid @emcrit @pharmertoxguy Yes sir, I do! No bolus & titrate up. Less overall BDZ & res depress...
— Haney Mallemat (@CriticalCareNow) December 28, 2012
MT @arikestler: Who uses dexmedetomidine 4 EtOH wthdrwl @critcareguys @criticalcarenow @cliffreid @emcrit @pharmertoxguy Have used clonidine
— Cliff Reid (@cliffreid) December 29, 2012
Many institutions utilize nurse-driven alcohol withdrawal scales allowing them the autonomy to give patients symptom-triggered benzodiazepine therapy based on an objective score. ED nurses may not be as familiar with proper titration of dexmedetomidine, particularly in non-intubated patients. It may be prudent to have guidelines in place to ensure safe administration and good patient outcomes.
Original: February 7, 2013
Updated: May 20, 2013
References
[1] Muzyk AJ, Fowler JA, Norwood DK, et al. Role of alpha-2 agonists in the treatment of acute alcohol withdrawal. Ann Pharmacother 2011;45:649-57. [PMID 21521867]
[2] DeMuro JP, Botros DG, Wirkowski E, et al. Use of dexmedetomidine for the treatment of alcohol withdrawal syndrome in critically ill patients: a retrospective case series. J Anesth 2012;26(4):601-5. [PMID 22584816]
[3] Tolonen J, Rossinen J, Alho H, et al. Dexmedetomidine in addition to benzodiazepine-based sedation in patients with alcohol withdrawal delirium. Eur J Emerg Med 2012 [Epub ahead of print]. [PMID 23247391]
[4] Rayner SG, Weinert CR, Peng H, et al. Dexmedetomidine as adjunct treatment for severe alcohol withdrawal in the ICU. Ann Intensive Care 2012;2(1):12. [PMID 22620986]
You can view the real-time results from the Peer Review Demographics form.
I recently mentioned this topic in a lecture I gave to our EM residency here in Chicago. One of our toxicologists strongly recommend against the use of Precedex in alcohol withdrawal after I had mentioned I used it successfully in our ICU on several occasions. His argument was that Precedex does not actually treat the GABA-depletion cause of the withdrawal, it just masks it. He made an analogy to giving paralytics to a seizing patient. So it may be a good adjunct to use in addition to BZDs, but I've definitely reconsidered using it as a stand-alone agent.
ReplyDeleteExactly, I think that's the point that Bryan is making - ADJUNCT to benzos. Thanks for the explanation for why dexmedetomidine should NOT be used as a single agent approach. Thanks!
DeleteA very enticing idea on the surface, however I see no need for two agents when one will do. Particularly when the benefit (less respiratory depression) is not an outcome that matters in the vast majority of severe withdrawal cases. Tell me it saves lives and then maybe it will tip the scales away from the hazards of poly-pharmacy (medication errors, increasing adverse reactions, masking of withdrawal symptoms, unintended downstream consequences to name a few) towards the use of Precedex as an adjunct therapy.
ReplyDelete