Using 2 benzos for alcohol withdrawal

[Kuvan]

Hi. I'm a pharmacist working at a psych hospital. Just wondering why some of the docs at my hospital use chlordiazepoxide and oxazepam for the first dose for some patients. One doc ordered oxazepam 60 mg and chlordiazepoxide 50 mg X 1. Recently I had orders for oxazepam 30 mg and chlordiazepoxide 25 mg X 1. When I asked, the charge nurse told me the patient scored 25 on CIWA-Ar. My question is, what's the reason behind the combo? Oxazepam has a slower onset vs chlordiazepoxide and a shorter duration vs chlordiazepoxide. Why not just use chlordiazepoxide monotherapy?

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[Shufflin]

Doctor #1: I think a short-acting mixed with a long-acting benzo for alcohol detox sounds good to me. Serax with Librium. Brilliant!

Doctor #2: Never seen Serax with Librium before. Must be the culture at this place. Ok, makes some sense, I'll do it too.

Doctor #3: I see that two doctors have prescribed Serax with Librium for alcohol detox. Must be the culture here. Why not.

Doctor #4: Hmm, the nurse told me other doctors prescribed Serax with Librium for alcohol detox. Must be the culture here. Ok

Rinse and repeat...

You can just use Librium or Valium mono is fine.

 

[hallowmann]

Regularly use Librium monotherapy, especially if we're doing a taper. Also starting to use gabapentin tapers more consistently to avoid unnecessary benzos on non-severe withdrawal patients.

 

[FlowRate]

There are reasons to use oxazepam alone but they are never compatible with using librium.

 

[MacDonaldTriad]

Oxazepam is good when you are dealing with bad livers because it lacks active metabolites and is easily conjugated. Mixing it with Librium makes zero sense and is like chewing sugar free gum while drinking a soda.

 

[Duloxetini]

Oxazepam is good when you are dealing with bad livers because it lacks active metabolites and is easily conjugated. Mixing it with Librium makes zero sense and is like chewing sugar free gum while drinking a soda.

What if the soda is diet tho?

Real talk : we have a patient like that now so that totally makes sense re metabolites

 

[TexasPhysician]

Why use either when Lorazepam exists? #lorazepamisbest

 

[FlowRate]

Why use either when Lorazepam exists? #lorazepamisbest

Sometimes we gave patients discharging from our detox unit a single dose of librium at discharge to finish their taper. Otherwise I agree that ativan is my preference for supervised withdrawal treatment.

 

[Sushirolls]

There are so many ways to 'skin the cat' when it comes to alcohol detox. Don't over think it. I'm not aware of any data that drives a monotherapy emphasis like there is with Antipsychotics for Schizophrenia.

 

[MacDonaldTriad]

Some might argue that all Benzos work the same, but I would point out that the rates of absorption, the lipophillisity (if that is a word) / redistribution rates, and the mode of metabolism vary a lot. Using multiple Benzos will confuse all of these things and since they work more or less the same way, what reason would there be to use more than one?

 

[Kuvan]

Haha! Thanks for all the replies. I asked the doc who prescribed it today. I told him that oxazepam wasn't fast onset and it's short acting, so it didn't make sense to me when I saw it combined with librium. He told me that he might be wrong, but his reason behind it was to cover the withdrawal with librium and to use oxazepam to fill in the gap? It's a one dose deal. ?? He drew a diagram for me and basically had the oxazepam peaked higher than chlordiazepoxide. So, in his mind, short acting oxazepam will have a higher peak than the long acting librium. Then he used an analogy of methadone, long acting, and using a short acting opioid to cover the breatkthrough pain. But we are not talking about breakthrough pain. We monitor pt using CIWA-Ar. Pt scored 25 on CIWA-Ar upon admission. We have a protocol for that. We usually use symptom-triggered regimen with oxazepam. Good drug for pts with liver problems. Sometimes we use Librium taper - 50 mg TID for 3 doses and then 25 mg TID for 3 doses and then stop. Another doc didn't understand the reason behind combining librium and Serax. Oh well, to each his own. Thanks for all the answers! Much appreciated.

 

[Kuvan]

And we have a new doc that puts everyone on gabapentin 600 mg TID with no stop date for sz prophylaxis on top of benzo when she first started on the unit. Then she lowered the dose instead of starting everyone on 600 mg TID. Now she uses depakote DR 500 mg BID for 3 days. Don't know what changed. The previous doc liked to use Keppra for sz prophylaxis. Does everyone have to be on sz prophylaxis? I thought unless pt has hx of sz from w/drawal or pt has hx of sz, benzo usually would take care of the sz part.

 

[Kuvan]

What if the soda is diet tho?

Real talk : we have a patient like that now so that totally makes sense re metabolites

Since your user name is Duloxetini, could you please explain why duloxetine's absorption is so strange? There is a 3 hour delay in absorption and a one-third increase in apparent clearance of duloxetine after an evening dose as compared to a morning dose - per package insert. My question is if the pt is started on BID dosing, it won't be a problem. But what if the pt has been on let's say 60 mg once daily for months and the doc decides to change it to 30 mg BID. Will the pt respond to the BID dosing differently since the pK is slightly different?

 

[phyonaphan]

Oxazepam and Lorazepam in alcohol detox are meds of choice if someone has liver disease, because of their metabolic qualities that spare liver metabolism.

Otherwise I use Diazepam as the benzo of choice for alcohol detox because of it's long half life. Librium has a longer half life but not available in all countries, including Australia. There is little rationale to combine Benzos unless because of patient characteristics. For example an Intramuscular medication may be required to be prescribed if a patient is at risk of acute behavioural disturbance that may require an IM to be given or if refusing oral medication (as permitted by relevant legislation). In my jusristiction that would be IM Lorazepam, which would be justified to prescribe with PO Diazepam as it is not readily available on psych units as an IM preparation (and arguably not the benzo of choice to contain an acutely aggressive patient)

 

[FlowRate]

And we have a new doc that puts everyone on gabapentin 600 mg TID with no stop date for sz prophylaxis on top of benzo when she first started on the unit. Then she lowered the dose instead of starting everyone on 600 mg TID. Now she uses depakote DR 500 mg BID for 3 days. Don't know what changed. The previous doc liked to use Keppra for sz prophylaxis. Does everyone have to be on sz prophylaxis? I thought unless pt has hx of sz from w/drawal or pt has hx of sz, benzo usually would take care of the sz part.

IIRC there's no evidence supporting the use of AED's to prevent alcohol-withdrawal induced seizures. Moreover, withdrawal seizures are typically "benign." If they're in status, there's probably something else going on than just withdrawal.

 

[clausewitz2]

IIRC there's no evidence supporting the use of AED's to prevent alcohol-withdrawal induced seizures. Moreover, withdrawal seizures are typically "benign." If they're in status, there's probably something else going on than just withdrawal.

Yes, this is a garbage practice.

Also why on Earth would you be giving Keppra to someone who is inpatient psychiatrically unless absolutely necessary (like well-documented epilepsy)? Why pick the AED most likely to make someone depressed/agitated?

I mean, I know the reason (you don't have to really think about dosing or levels) but it is just laziness all around.

 

[Kuvan]

Yes, this is a garbage practice.

Also why on Earth would you be giving Keppra to someone who is inpatient psychiatrically unless absolutely necessary (like well-documented epilepsy)? Why pick the AED most likely to make someone depressed/agitated?

I mean, I know the reason (you don't have to really think about dosing or levels) but it is just laziness all around.

I agree, but I'm just a pharmacist. I don't think they will listen to me. It's almost like what I read and learned in school are totally different from what I see in practice. I think the patients are being medicated unnecessarily. It's not like there aren't side effects adding Depakote DR, Keppra, and high doses of gabapentin solely for sz prophylaxis when the pts have no hx of sz or hx of sz from alcohol withdrawal. Everyone gets the cocktail. Oh well, to each his own. But thank you guys for all your replies. It helps a lot!

 

[Kuvan]

IIRC there's no evidence supporting the use of AED's to prevent alcohol-withdrawal induced seizures. Moreover, withdrawal seizures are typically "benign." If they're in status, there's probably something else going on than just withdrawal.

I agree 100%. Thank you!

 

[spaceydaisy]

I agree, but I'm just a pharmacist. I don't think they will listen to me. It's almost like what I read and learned in school are totally different from what I see in practice. I think the patients are being medicated unnecessarily. It's not like there aren't side effects adding Depakote DR, Keppra, and high doses of gabapentin solely for sz prophylaxis when the pts have no hx of sz or hx of sz from alcohol withdrawal. Everyone gets the cocktail. Oh well, to each his own. But thank you guys for all your replies. It helps a lot!

FWIW, I love hearing from pharmacists. I'm always eager to learn what they know about pharmacodynamics and med interactions and stuff when they have thoughts about what I'm prescribing. I'm at an academic center, so everyone is very mindful of being as evidence based as we can be.

 

[Kuvan]

FWIW, I love hearing from pharmacists. I'm always eager to learn what they know about pharmacodynamics and med interactions and stuff when they have thoughts about what I'm prescribing. I'm at an academic center, so everyone is very mindful of being as evidence based as we can be.

Thank you. I love learning from clinicians. Absolutely love it when doctors have time to explain why they do what they do.