Emerging treatment options in the alcohol withdrawal syndrome

Severe alcohol withdrawal has a mortality rate of 5% to 10%. Uncontrolled bouts may sensitize the patient, making future episodes more frequent and severe. Thus, aggressive treatment that produces rapid control of alcohol withdrawal is essential. The author briefly discusses some of the neuropharmacological aspects of alcohol's actions and alcohol withdrawal. Drug treatment options are also considered. Benzodiazepines offer the highest margin of safety. Lorazepam is an excellent first choice because of its intermediate half-life, absence of active metabolites, and high bioavailability that can be achieved with a number of routes of administration. Combination therapy with clonidine, beta-adrenergic blocking agents, and haloperidol is becoming increasingly attractive because it results in decreased sedation, better control of delirium, less respiratory depression, and improved outcome. The availability of shorter half-life, rapid-acting drugs like esmolol and midazolam, administered by continuous infusion, makes dose titration more precise in the critically ill patient.