[Treatment alternatives of alcohol withdrawal delirium]

The choice of treatment in alcohol withdrawal syndromes (clomethiazole, benzodiazepines, neuroleptics or clonidine) is still a subject of dispute. After administration of ethanol, the CNS shows significant short and long-term changes in a number of transmitter-systems (e.g. noradrenaline, GABA, glutamate, dopamine), which--at least partially--explain the variety of symptoms in alcohol withdrawal and may indicate a correlation between the symptoms and the transmitter systems affected. An optimal drug would have to meet a wide range of criteria, combining good antiadrenergic, anticonvulsive and antipsychotic properties with a high margin of therapeutic safety and good controllability. With respect to monotherapy, clomethiazole and to a lesser degree also benzodiazepines are most likely to fulfil these criteria, both theoretically and in the light of comparative studies. Combined therapy has some advantages in theory, but is not yet backed by sufficient empirical evidence. We recommend a graduation of therapy according to the severity of withdrawal symptoms, starting with adjuvant measures and orally administered clomethiazole, while i.v. application of clomethiazole on an ICU is necessary in fully developed delirium tremens. Additional therapy with potent neuroleptics is reasonable, if psychotic symptoms persist. Other combinations may be applied in individual cases according to the prevailing symptoms.