Benzodiazepine-free treatment tied to favorable withdrawal outcomes

Implementation of treatment for alcohol withdrawal symptoms without benzodiazepines was associated with decreased use of the drug and favorable outcomes, according to a quality improvement study published in JAMA Network Open.

“While BZDs are associated with effective reductions in [alcohol withdrawal syndrome] AWS symptoms, they are also associated with adverse effects, including excessive sedation, falls, respiratory depression, aspiration, delirium, and even mortality,” Joshua T. Smith, PharmD, of the division of research at Kaiser Permanente, and colleagues wrote. “Alternate AWS treatments have been suggested, including anticonvulsants and alpha-2 adrenergic agonists. However, the evidence supporting these treatments is limited, with a handful of small prospective trials and retrospective studies suggesting benefit.”

Researchers sought to analyze changes in outcomes following installation of a benzodiazepine-sparing AWS inpatient order set that included secondary drug therapies (eg, gabapentin, valproic acid, clonidine and dexmedetomidine).

From a pool of more than 900,000 hospitalizations, the researchers examined 22,899 hospitalizations among 16,323 unique patients (mean age 57.1, 68.8% male) with AWS from Oct. 1, 2014, to Sept. 30, 2019, in the Kaiser Permanente Northern California integrated health care delivery system. Data were subsequently analyzed from September 2020 through November 2021.

Results showed that 12,889 (56.3%) hospitalizations used an order set for alcohol withdrawal. Among those, any use of benzodiazepine decreased following implementation from 6,431 hospitalizations to 2,823 (P <.001), with parallel decreases in the mean total dosage of lorazepam before vs. after set execution (19.7 [38.3] mg vs. 6.0 [9.1] mg; P<.001).

Significant reductions were also revealed through the use of adjunctive medications, including gabapentin, clonidine, thiamine, valproic acid and phenobarbital. Data also showed that use of the benzodiazepine-sparing treatment was associated with decreases in visits to intensive care units (adjusted rate ratio, 0.71; 95% CI, 0.56-0.89) and length of hospitalization (adjusted rate ratio, 0.71; 95% CI, 0.58-0.86).

“While our evaluation suggests that the postimplementation order set was associated with a decrease in ICU admission and hospital [length of stay], future prospective studies are needed to confirm these findings,” Smith and colleagues wrote.