Benzodiazepines for Alcohol Withdrawal

A Cochrane review [Abstract] 1 included 64 studies with a total of 4 309 subjects. Benzodiazepines offered a large benefit against alcohol withdrawal seizures compared to placebo (RR 0.16, 95% CI 0.04 to 0.69; 3 studies, n=324). There were no statistically significant differences when benzodiazepines were compared with other drugs for seizure (RR 0.52, 95% CI 0.21 to 1.31; 12 studies, n=1228) and delirium control (RR 0.65, 95% CI 0.21 to 1.98, statistical heterogeneity I² =52%; 8 studies, n=893), severe life threatening side effect (RR 1.95, 95% CI 0.25 to 15.28; 7 studies, n=340), dropouts (RR 0.93, 95% CI 0.70 to 1.24; 22 studies, n=1848), dropouts due to side effects (RR 0.82, 95% CI 0.23 to 2.88; 8 studies, n=533) and patient's global assessment score (RR 1.04, 95% CI 0.97 to 1.12; 2 studies, n=140). A trend in favour of other drug group was observed for CIWA-Ar scores at 48 hours and at the end of treatment; the results reached statistical significance only in one study (results on Hamilton anxiety rating scale favoured other drug group, MD -1.60, 95% CI -2.59 to -0.61; 1 study, n=43).

There were no statistically significant differences when different benzodiazepines were compared among themselves, although chlordiazepoxide seemed to perform better than other benzodiazepines.Three studies (n=262) compared fixed versus symptom-triggered schedules of a benzodiazepine (chlordiazepoxide, oxazepam, flunitrazepam) for various outcomes. There was a small significant benefit of symptom-triggered regimens regarding CIWA-Ar score (change from baseline) at 48 hrs (MD -5.70, 95% CI -11.02 to -0.38; 1 study, n=44). No other statistically significant differences were found.

Another Cochrane review [Abstract]2 included 114 studies with a total of 7333 participants. Comparing each of the five treatments versus specific class of drugs, benzodiazepines performed better than antipsychotics for seizures (RR 0.24, 95% CI 0.07 to 0.88; 4 studies, n=633.

Comment: The quality of evidence is downgraded by study quality (unclear allocation concealment) but upgraded by large magnitude of effect.

The following decision support rules contain links to this evidence summary:

• Treatment of alcohol withdrawal symptoms http://www.ebmeds.org/ebmeds/ebmeds_home.asp?mode=scripts&submode=view&id=scr00041&country=UK

References

• Amato L, Minozzi S, Vecchi S, Davoli M. Benzodiazepines for alcohol withdrawal. Cochrane Database Syst Rev 2010;(3):CD005063. [PubMed].
• Amato L, Minozzi S, Davoli M. Efficacy and safety of pharmacological interventions for the treatment of the Alcohol Withdrawal Syndrome. Cochrane Database Syst Rev 2011;(6):CD008537. [PubMed]