(925) Benzodiazepine-Sparing Regimen for Management of Alcohol Withdrawal in a Medical ICU

Introduction: Alcohol withdrawal has traditionally been managed with benzodiazepines. However, concerns about their adverse effects have prompted exploration of alternative treatments. Studies have examined the efficacy of non-benzodiazepine agents in treating and preventing alcohol withdrawal including the use of clonidine, gabapentin, pregabalin, and valproic acid (VPA). This case series aims to describe the use of a benzodiazepine-sparing regimen (BZD-S) for the treatment of alcohol withdrawal in a medical intensive care unit (MICU).

Methods: A single-center, retrospective review of patients admitted to the MICU at an academic medical center who received BZD-S for the treatment of alcohol withdrawal from January 1, 2023 to May 31, 2024 was performed. Patients receiving BZD-S had orders for clonidine patches, a gabapentinoid or VPA, and a benzodiazepine for breakthrough symptoms. Patients were excluded if they received components of the regimen for indications other than alcohol withdrawal.

Results: Twenty-five patients were identified for review, of which 15 encounters met inclusion criteria. The most frequently prescribed regimens were clonidine/gabapentin, clonidine/pregabalin, and clonidine/pregabalin/VPA accounting for 40%, 33.3%, and 13.3%, respectively. The mean maximum Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) scores pre and post BZD-S were 19 and 15.6. The average cumulative benzodiazepine dose before BZD-S was 13 mg lorazepam equivalents compared to 5.5 mg lorazepam equivalents after initiation. There were 5 patients who did not require adjunctive benzodiazepines. There was no incidence of mechanical ventilation, breakthrough seizures or death. Hypotension, defined as a mean arterial pressure less than 65 mmHg, occurred in 5 patients (33.3%), but none required initiation of vasopressors.

Conclusions: In the observational cohort, the maximum CIWA-Ar scores and cumulative benzodiazepine requirements were lower after initiation of BZD-S. A third of patients experienced hypotension, however, interpretation is limited by a small sample size. Comparative trials assessing outcomes between BZD-S and traditional benzodiazepine based treatment are needed to further evaluate the safety and efficacy of this treatment strategy in critically ill alcohol withdrawal patients.