Monday, October 24, 2011

Is baclofen ready for prime time in the treatment of alcohol withdrawal?

This has been a subject of numerous recent papers. A study just published in the Journal of Hospital Medicine looked at whether baclofen usage could reduce the required dose of lorazepam given in a symptom driven protocol. Here were the findings:

The 44 subjects who developed symptoms of AWS were randomized to baclofen or placebo. Thirty-one subjects (18 baclofen, 13 placebo) completed 72 hours of assessments, either entirely as inpatients or with outpatient follow-up. The need for high doses of benzodiazepines (20 mg or more of lorazepam over 72 hours) to control AWS was less likely in the baclofen treatment group (1 of 18) than in the placebo-treated group (7 of 13) (P = 0.004).

We need to note a couple of things about this study. First, it was very small. Second is the question of outcomes. The outcome of this study was the dose of lorazepam required in a symptom driven protocol. But is the requirement of more lorazepam necessarily a worse outcome? What we'd really like to know is whether patients receiving baclofen remain more alert, are better able to eat, are less likely to require mechanical ventilation, have shorter ICU and hospital stays and, of course, have a lower mortality. The baclofen story will unfold. This was of interest not a study to change practice.

This raises the whole subject of adjunctive drugs for alcohol withdrawal such as baclofen, clonidine and antipsychotics. I recently searched this question in UptoDate. The authors there favor sticking with benzos, and giving enough, and generally avoiding adjunctive medications.

HT to Hospital Medicine Quick Hits.

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