The MKSAP Challenge
Answer: B
Educational objective: Recognize that, in acute alcohol withdrawal, symptom-triggered dosing of benzodiazepines is more effective.
This patient should be hospitalized because he is hallucinating and is hypertensive. The risk of seizures in this setting is 3%, usually with 48 hours of withdrawal.
Benzodiazepines are the mainstay of therapy in the patient with acute alcohol withdrawal. In general, the long-acting benzodiazepines such as diazepam are preferred. Three dosing regimens have been used with these medications. A front-loaded approach uses a fairly large dose of a long-acting medication and lets it slowly be metabolized. A fixed regimen uses a gradual, set taper and the symptom-triggered uses the Clinical Institute Withdrawal Assessment scale to determine level of withdrawal and doses accordingly. This final option leads to less total benzodiazepine use and faster discharge.
References:
1. Fiellin DA, Reid MC, O'Connor PG. Outpatient management of patients with alcohol problems. Ann Intern Med. 2000;133:815-27.
2. Daeppen JB, Gache P, Landry U, Sekera E, Schweizer V, Gloor S, Yersin B. Symptom-triggered vs fixed-schedule doses of benzodiazepine for alcohol withdrawal: a randomized treatment trial. Arch Intern Med. 2002;162:1117-21.
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