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**docB** · 06-11-2003, 05:07 PM

Someone just told me about this small, Italian study where they used Baclofen to treat DTs in patients that they were sending out. They only studied 5 pts but they had good results. Has anyone tried this? I know one doc that said she has had good results.
I'm still using benzos, which is problematic because you have to give them quite a few to treat them effectively and if they down the batch you're hosed medicolegally. I have used phenobarb a few times but I don't like it because it always seems to put them out for hours and they're stuck in the ER.

American Journal of Med. 2002, Feb 15;112(3):226-9
Rapid suppression of alcohol withdrawl syndrome by baclofen

emedpa · 06-11-2003, 07:11 PM

we use clonidine 0.1 mg-0.3 mg tid here if bp allows. never tried baclofen...

**southerndoc** · 06-11-2003, 07:26 PM

You would probably have difficulty defending yourself in front of a jury for giving a med that was studied in only 5 patients.

Remember, DT's has a significant mortality rate -- even when treated. Until baclofen is studied more extensively, I'd shy away from it.

Wrangler · 06-11-2003, 10:54 PM

I agree with geek medic and assume pretty mild withdrawal to be d/c'd. Why not admit for (or to) detox. If they don't want to go, why not give them a dose of Phenobarb for the road until they can get back to drinking (which they will be doing shortly after d/c without a detox program). I'm not sure what the benefit of giving sedatives is while someone is heavily drinking alcohol. (though people still do it) My in the ED personal best for DT's is 32mg of Ativan IV in 2mg increments and he was still tremulous and unintubated (others have beat that here).

**docB** · 06-12-2003, 08:41 AM

Quote:

I agree with geek medic and assume pretty mild withdrawal to be d/c'd. Why not admit for (or to) detox. If they don't want to go, why not give them a dose of Phenobarb for the road until they can get back to drinking (which they will be doing shortly after d/c without a detox program). I'm not sure what the benefit of giving sedatives is while someone is heavily drinking alcohol. (though people still do it) My in the ED personal best for DT's is 32mg of Ativan IV in 2mg increments and he was still tremulous and unintubated (others have beat that here).

As I mentioned I've had bad luck with phenobarb because it over sedates them and they get stuck in my ER, even at low doses. The reason you give sedatives to these patients is that you need to give them GABAergic meds to counter their up regulated NMDA stimulation that happens when they withdraw. One of the other disadvantages of phenobarb is that its long halflife means that it will still be around when they get back to the bar.
As for admitting to detox, not an option at any of the hospitals where I work. Even the private detoxes that a few pts are lucky enough to get into send all intoxicated or DT pts to the ED.

Quote:

Remember, DT's has a significant mortality rate -- even when treated. Until baclofen is studied more extensively, I'd shy away from it.

As mentioned, I'm talking about the DT pts that are going to get d/cd anyway. I'm curious if anyone has used it and what their experiences are.

Quote:

we use clonidine 0.1 mg-0.3 mg tid here if bp allows. never tried baclofen...

How does clonidine work? I use it for heroin w/d but haven't tried it for DTs.

emedpa · 06-12-2003, 05:25 PM

it works ok for mild cases but not as well as benzos overall.

Wrangler · 06-12-2003, 07:03 PM

Sorry -Of course ED BDZ's or whatever is fine in the ED. I meant that it dosen't make since to give outpatient perscriptions (unless you are really desperate, and even then just a day or two worth with a responsible supervisor and daily returns for checks).

I'm not sure why detox would send detoxing patients back to the ED (when I say detox, I mean for active withdrawal and DT's, not a rehab facility without the medical detox capability). By definition DTs are a symptom of severe withdrawal from alcohol, which about 5% or less of alcoholics in withdrawal experience (emphasis on "delerium" not tremens).

The big advantage of phenobarb is its long half-life (24-96 hours) which means that no outpatient scripts are necessary for d/c.

If no detox program available, patients who don't respond well to one or two doses of sedative should be admitted (some sources say about 8mg+ ativan or 500mg+ of phenobarb comes in) to medicine for detox = large doses of IV sedatives tapered over days.

**southerndoc** · 06-12-2003, 07:40 PM

Quote:

Originally posted by docB
How does clonidine work? I use it for heroin w/d but haven't tried it for DTs.

Our WASP (withdrawal from alcohol standard protocol) protocol calls for clonidine or lebatolol prn to control blood pressure only. Ativan or Librium are the primary treatments (along with some haldol prn).

**droliver** · 06-12-2003, 08:16 PM

Quote:

Originally posted by emedpa
it works ok for mild cases but not as well as benzos overall.

Clonidine serves a completely different purpose for this. It's used to blunt some of the CV lability effects of withdrawal rather then prophylax or treat the DT phase

**docB** · 06-13-2003, 12:39 PM

I'd say that the rule, not the exception, is that ERs and hospitals are the detox centers. Few communities have acute detox facilities specifically for treatment of active DTs. Where I am it is the ICU.
Again, I'm talking about the very mild DTers who are going to be DCd. Aside from the over sedation that I've run into I worry about the long half life of phenobarb. That long half life eliminates the need for a Rx but it will still be in their system when they get back to their bottle of Thunderbird. Etoh on top of the phenobarb is much more dangerous than etoh on top of benzos (ask the Heaven's Gate crowd).
Basically the phenobarb can be oversedating and possibly dangerous, benzos require giving an unreliable person a bottle of dangerous pills and you can't admit everyone. If there are newer, better therapies on the horizon I'm game.

KGUNNER1 · 06-14-2003, 07:56 PM

Be very careful about throwing around terminology that has very different meanings. Delerium Tremens and Alcohol withdrawl symptoms are two distinct entities on the spectrum of alcohol abuse. You never send DT's home and there aren't "mild cases" of DT's. DT's are a very serious hyperadrenergic and neurologic crisis that many times requires airway protection, heavy sedation with benzodiazipines, alpha and beta blockade and ICU admission.

Alcohol withdrawl symptoms can range from the shakes to tachycardia etc... You can even have seizures associated with this. Current recommended treatment is Benzo's or phenobarb (more sedation) as first line agents ONLY. Tegretol, Clonidine, Beta-blockers etc. are only adjuncts. No one in the ED should treat withdrawl symptoms with the adjuncts alone. There was a recent review in NEJM 2003 as well as a very nice meta-analysis in Jama 1997. NEJM also reported a trial in VA patients (1999) showing that ativan is superior to dilantin in alcohol withdrawl seizures.

Since seizures are common in alcohol withdrawl, and benzos control seizures as well as the hyperadrenergic response, it is a reasonable first line agent. All the adjunts work either on the hyperadrenergic symptoms or the neurologic hyper-responsiveness (seizure threshold).

Cheers
Kyle

sundermannr · 06-15-2003, 09:20 AM

Kyle,
Have you guys tried dexmetetomidine (sp?) for sedation and DT control in the ICU. Its expensive but it does a similar job on the hyperadrenergic symptoms like clonidine and has a nice sedative effect where they can still respond and aren't too gorked out.
ryan

KGUNNER1 · 06-15-2003, 02:20 PM

Ryan,
We looked into using dexmedetomidine as an alternative to sedation. We currently use a lot of propofol, which is great for short term sedation, and in hepatic and renal failure patients (which we see so much of) but has its drawbacks. So when Presedex came out we wanted to put it on formulary. As you know it is a cousin of etomidate. As you probably also know, etomidate used to kill people when used as a continuous infusion (due to adrenal supression). Appearantly Presedex doesn't have this side effect and the hemodynamic profile is similar. However the wise ones who hold the key to our formulary wouldn't approve it, so we don't have it and I have no experience with it, for anything. I did remember reading an article about it in withdrawl sx. Unless participating in an experimental trial, I would stick to the tried and true first.

Kyle

FabFrank · 06-24-2003, 06:30 PM

We used a fair amount of Dexmed for sedation during my SICU rotation. If I recall correctly, it was only approved for 24 hours of sedation, but we regularly had pt's on it for 3-7 days before switching them to another sedative or weaning them off. I can't recall any adverse events due to its use.

KGUNNER1 · 06-24-2003, 08:17 PM

The key selling point for dexmedetomidine is its very nice hemodynamic profile and the ability to extubate patients on this while still providing some low level of sedation. I would say it is not uncommon when trying to extubate someone, you rapidly wake them up by stopping all sedation, then throw them on a t-piece or some low level of pressure support and quite often they panic and hyperventilate. So the RT and resident reports that they failed their weaning trial and puts them back on the vent for 24 more hours. When in fact their lungs were fine, it was just between the ears that was the problem.

06-11-2003, 05:07 PM	#1
docB Chronically painful Status: Attending Join Date: Nov 2002 Location: Las Vegas, NV Posts: 4,899	Baclofen for DTs? SDN Members don't see this ad. Someone just told me about this small, Italian study where they used Baclofen to treat DTs in patients that they were sending out. They only studied 5 pts but they had good results. Has anyone tried this? I know one doc that said she has had good results. I'm still using benzos, which is problematic because you have to give them quite a few to treat them effectively and if they down the batch you're hosed medicolegally. I have used phenobarb a few times but I don't like it because it always seems to put them out for hours and they're stuck in the ER. American Journal of Med. 2002, Feb 15;112(3):226-9 Rapid suppression of alcohol withdrawl syndrome by baclofen __________________ Emergency Medicine - Saving the world from seeing its primary care doctor. Would you like some Dilaudid with that? Donate to SDN!

06-11-2003, 07:11 PM	#2
emedpa Senior Member Join Date: Aug 2001 Location: Lunch on the Summit Posts: 3,393	we use clonidine 0.1 mg-0.3 mg tid here if bp allows. never tried baclofen... __________________ Emergency Medicine P.A., EMT-P 22 Years working in EM

06-11-2003, 07:26 PM	#3
southerndoc life is good Status: Attending Join Date: Jun 2002 Location: Atlanta & DC Posts: 9,899	You would probably have difficulty defending yourself in front of a jury for giving a med that was studied in only 5 patients. Remember, DT's has a significant mortality rate -- even when treated. Until baclofen is studied more extensively, I'd shy away from it. __________________ there is more to life than increasing its speed

06-14-2003, 07:56 PM	#11
KGUNNER1 Senior Member Status: Attending Join Date: Nov 2002 Location: Virginia Posts: 249	Be very careful about throwing around terminology that has very different meanings. Delerium Tremens and Alcohol withdrawl symptoms are two distinct entities on the spectrum of alcohol abuse. You never send DT's home and there aren't "mild cases" of DT's. DT's are a very serious hyperadrenergic and neurologic crisis that many times requires airway protection, heavy sedation with benzodiazipines, alpha and beta blockade and ICU admission. Alcohol withdrawl symptoms can range from the shakes to tachycardia etc... You can even have seizures associated with this. Current recommended treatment is Benzo's or phenobarb (more sedation) as first line agents ONLY. Tegretol, Clonidine, Beta-blockers etc. are only adjuncts. No one in the ED should treat withdrawl symptoms with the adjuncts alone. There was a recent review in NEJM 2003 as well as a very nice meta-analysis in Jama 1997. NEJM also reported a trial in VA patients (1999) showing that ativan is superior to dilantin in alcohol withdrawl seizures. Since seizures are common in alcohol withdrawl, and benzos control seizures as well as the hyperadrenergic response, it is a reasonable first line agent. All the adjunts work either on the hyperadrenergic symptoms or the neurologic hyper-responsiveness (seizure threshold). Cheers Kyle __________________ EM/IM Critical Care

06-24-2003, 06:30 PM	#14
FabFrank Member Join Date: Feb 2003 Posts: 47	We used a fair amount of Dexmed for sedation during my SICU rotation. If I recall correctly, it was only approved for 24 hours of sedation, but we regularly had pt's on it for 3-7 days before switching them to another sedative or weaning them off. I can't recall any adverse events due to its use. __________________ RLTW

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06-11-2003, 10:54 PM	#4
Wrangler Member Join Date: Mar 2003 Location: Northeast Posts: 27	I agree with geek medic and assume pretty mild withdrawal to be d/c'd. Why not admit for (or to) detox. If they don't want to go, why not give them a dose of Phenobarb for the road until they can get back to drinking (which they will be doing shortly after d/c without a detox program). I'm not sure what the benefit of giving sedatives is while someone is heavily drinking alcohol. (though people still do it) My in the ED personal best for DT's is 32mg of Ativan IV in 2mg increments and he was still tremulous and unintubated (others have beat that here).

06-12-2003, 05:25 PM	#6
emedpa Senior Member Join Date: Aug 2001 Location: Lunch on the Summit Posts: 3,393	it works ok for mild cases but not as well as benzos overall.

06-12-2003, 07:03 PM	#7
Wrangler Member Join Date: Mar 2003 Location: Northeast Posts: 27	Sorry -Of course ED BDZ's or whatever is fine in the ED. I meant that it dosen't make since to give outpatient perscriptions (unless you are really desperate, and even then just a day or two worth with a responsible supervisor and daily returns for checks). I'm not sure why detox would send detoxing patients back to the ED (when I say detox, I mean for active withdrawal and DT's, not a rehab facility without the medical detox capability). By definition DTs are a symptom of severe withdrawal from alcohol, which about 5% or less of alcoholics in withdrawal experience (emphasis on "delerium" not tremens). The big advantage of phenobarb is its long half-life (24-96 hours) which means that no outpatient scripts are necessary for d/c. If no detox program available, patients who don't respond well to one or two doses of sedative should be admitted (some sources say about 8mg+ ativan or 500mg+ of phenobarb comes in) to medicine for detox = large doses of IV sedatives tapered over days.

06-13-2003, 12:39 PM	#10
docB Chronically painful Status: Attending Join Date: Nov 2002 Location: Las Vegas, NV Posts: 4,899	I'd say that the rule, not the exception, is that ERs and hospitals are the detox centers. Few communities have acute detox facilities specifically for treatment of active DTs. Where I am it is the ICU. Again, I'm talking about the very mild DTers who are going to be DCd. Aside from the over sedation that I've run into I worry about the long half life of phenobarb. That long half life eliminates the need for a Rx but it will still be in their system when they get back to their bottle of Thunderbird. Etoh on top of the phenobarb is much more dangerous than etoh on top of benzos (ask the Heaven's Gate crowd). Basically the phenobarb can be oversedating and possibly dangerous, benzos require giving an unreliable person a bottle of dangerous pills and you can't admit everyone. If there are newer, better therapies on the horizon I'm game.

06-15-2003, 09:20 AM	#12
sundermannr Junior Member Join Date: Jan 2003 Posts: 16	Kyle, Have you guys tried dexmetetomidine (sp?) for sedation and DT control in the ICU. Its expensive but it does a similar job on the hyperadrenergic symptoms like clonidine and has a nice sedative effect where they can still respond and aren't too gorked out. ryan

06-15-2003, 02:20 PM	#13
KGUNNER1 Senior Member Status: Attending Join Date: Nov 2002 Location: Virginia Posts: 249	Ryan, We looked into using dexmedetomidine as an alternative to sedation. We currently use a lot of propofol, which is great for short term sedation, and in hepatic and renal failure patients (which we see so much of) but has its drawbacks. So when Presedex came out we wanted to put it on formulary. As you know it is a cousin of etomidate. As you probably also know, etomidate used to kill people when used as a continuous infusion (due to adrenal supression). Appearantly Presedex doesn't have this side effect and the hemodynamic profile is similar. However the wise ones who hold the key to our formulary wouldn't approve it, so we don't have it and I have no experience with it, for anything. I did remember reading an article about it in withdrawl sx. Unless participating in an experimental trial, I would stick to the tried and true first. Kyle

06-24-2003, 08:17 PM	#15
KGUNNER1 Senior Member Status: Attending Join Date: Nov 2002 Location: Virginia Posts: 249	The key selling point for dexmedetomidine is its very nice hemodynamic profile and the ability to extubate patients on this while still providing some low level of sedation. I would say it is not uncommon when trying to extubate someone, you rapidly wake them up by stopping all sedation, then throw them on a t-piece or some low level of pressure support and quite often they panic and hyperventilate. So the RT and resident reports that they failed their weaning trial and puts them back on the vent for 24 more hours. When in fact their lungs were fine, it was just between the ears that was the problem.

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