In these cases, we recommend that patients should be started immediately on a SML dose regimen, while monitoring the withdrawal severity (CIWA-Ar ratings) and clinical signs of tachycardia and hypertension. A fixed dose regimen can be safely used in such patients in case adequate trained personnel are not available or if outpatient treatment is advised.
This is a unique form of withdrawal related psychosis which can begin even while the person is continuing to use alcohol or begins after he stops alcohol. Hallucinations occurring in clear sensorium are the hallmark of this disorder. A cluster analysis of alcohol withdrawal symptoms by Driessen et al . showed that hallucinosis is a severe form of alcohol withdrawal and is often associated with DT. However, it is one of the conditions that may cause apparent failure of the loading dose regimen and we recommend a fixed dose strategy to cover the period of alcoholic hallucinosis. The patient may be given low doses of antipsychotics like chlorpromazine 100-200 mg/day or risperidone 1-3 mg/day to control severe agitation due to hallucinations. The hallucinations last about a week in most cases, but may last up to 1 month in some patients after which the antipsychotic can be stopped.
27. Wilkins AJ, Jenkins WJ, Steiner JA. Efficacy of clonidine in treatment of alcohol withdrawal state. Psychopharmacology (Berl) 1983;81:78-80.
Initially, assessment of common alcohol-related medical problems should be conducted. These complications include gastritis, gastrointestinal bleeding, liver disease, cardiomyopathy, pancreatitis, neurological impairment, electrolyte imbalances, and nutritional deficiencies. A physical examination should be performed to assess for arrhythmias, congestive heart failure, hepatic or pancreatic disease, infectious conditions, bleeding, and nervous system impairment.
We recommend that clinicians take into account the past history of seizures or DT as well as the current clinical status while deciding upon medications for a patient. In the presence of an acute medical illness at present or a past history of severe withdrawals, a single loading dose of 20 mg diazepam should preferably be given immediately and the patient be monitored for further signs of alcohol withdrawal. Further doses of diazepam (20 mg) should be given orally every 2 h until CIWA-Ar scores are less than ten. Up to three doses are required in most patients, which helps in reliably preventing the occurrence of withdrawal seizures. This strategy, which could aptly be called SML combines the principles and advantages of a STT, whereas at the same time takes into account a past history of severe withdrawals and gives a loading dose regardless of the appearance of symptoms.
9. Saunders JB, Janca A. Delirium tremens: its aetiology, natural history and treatment. Curr Opin Psychiatry 2000;13:629-633.