Definition and treatment of benzodiazepine-resistant ethanol withdrawal syndrome

What is it about?

Objective: To determine the most common definition of benzo- diazepine-resistant ethanol withdrawal syndrome (EWS) and assess practice variations in the use of phenobarbital for those patients. Methods: We conducted a four-part, 25 questions, online cross- sectional survey to assess different components of the evaluation and management of patients with EWS. The survey was con- ducted from 5 July to 18 September 2017 and deployed by email via administrators to the membership of the European Association of Poisons Centres and Clinical Toxicologists (EAPCCT), the Asia Pacific Association of Medical Toxicology (APAMT), the American Academy of Clinical Toxicology (AACT), the American College of Medical Toxicology (ACMT), and the Canadian Association of Emergency Physicians (CAEP). This study reports on two series of questions, which evaluated the definition of benzodiazepine-resistant EWS and use of phenobarbital in those patients. Respondents noted their preference for three common definitions for benzodiazepine-resistant EWS among Hack [1], NCT01652326 [2], and R.E.B.E.L. MD [3]. This study was approved by McGill University Health Centre Research and Ethics Board. Results: Overall, 356 individuals responded to the survey. Response rate was low but difficult to quantify due to cross membership. Participants were mostly physicians (82.3%) special- izing in emergency medicine (73.0%), aged 30–49 years (67%) with a range of experience. Clinicians were mostly practicing full- time (89.0%) in North America (91.8%), with 99% routinely treat- ing EWS. The most popular definitions of benzodiazepine-resist- ant EWS were: high benzodiazepine dosage (65.2%); seizures (24.4%); and persistent tachycardia (16.3%). Only 52 (14.6%) reported that a high score on an EWS assessment tool indicated benzodiazepine resistance. Preferences were split among avail- able definitions: Hack (28.0%); NCT01652326 (29.7%); and R.E.B.E. L. MD (28.0%). Phenobarbital was used most commonly for seiz- ures (41.6%) or a high benzodiazepine dosage (28.9%). Only 14 (3.9%) used phenobarbital for a high severity score or persistent tachycardia. Conclusion: This survey demonstrates wide practice variations in the definition and treatment of benzodiazepine-resistant EWS. However, we observed that high benzodiazepine dosage appears to be an important criterion for defining benzodiazepine resist- ance. A systematic review and consensus statement could help to guide optimal therapy.

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