Implementation of Symptom-Triggered Therapy for Adult Alcohol Withdrawal in a Hospital Setting
Sharon See, Department of Clinical Pharmacy Practice, College of Pharmacy and Health Sciences Beth Israel Residency in Urban Family Health and the Institute for Urban Family Practice, NY, NY
Sarah Nosal, MD, Robert Schiller, MD, Beth Israel Residency in Urban Family Health and the Institute for Urban Family Practice, NY, NY
Benzodiazepines are the standard of care for acute alcohol withdrawal syndrome (AWS). Fixed dosed therapy is designed to administer medication to a patient regardless of symptoms, whereas patients on symptom-triggered therapy only receive medication when symptoms of AWS are present. Currently, fixed-dose phenobarbital is used at our hospital even though national guidelines call for benzodiazepine treatment. This study evaluated the implementation of a pilot program, where patients receive symptom-triggered benzodiazepines (lorazepam or diazepam) for AWS. This retrospective, cohort study compared symptom-triggered benzodiazepine therapy with fixed-dose phenobarbital therapy for patients treated for AWS. In the symptom-triggered therapy protocol, the Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar) scale was utilized to determine whether or not a patient was to receive medication and the dose to be administered. We retrospectively collected data in 21 patients given this protocol from February 2005 to October 2006 and in 25 patients given phenobarbital from February 2004 to October 2005. The data collected included amount of medication used, duration of drug therapy, hospital length of stay, and adverse events. Overall, patients on the symptom-triggered protocol had lower rates of leaving the hospital against medical advice, used less medication and had a shorter length of stay. More importantly, 62% of the patients on the new protocol did not require any medication. These patients would have automatically received at least 5 days of phenobarbital if they were on the phenobarbital protocol. Patients in both cohorts had similar rates of adverse events. This pilot revealed that symptom-triggered benzodiazepine treatment is beneficial for the treatment of AWS. It also emphasized that making change in a large, hospital system requires support from administrators, collaboration from many departments and committed individuals to implement that change.