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Dexmedetomidine (Precedex) as an Adjunct to Benzodiazepines for Ethanol Withdrawal

Posted Feb 07 2013 12:00am

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Sometimes a question is posed on Twitter that generates a great discussion from colleagues 'round the globe. Here is one such example.
Who uses precedex for their EtOH withdrawal? What's your experience been? @ critcareguys @ criticalcarenow @ cliffreid @ emcrit @ pharmertoxguy
— Ari Kestler (@arikestler) December 28, 2012
Benzodiazepines remain the standard of treatment for ethanol withdrawal, particularly seizures and delirium tremens.

Alpha-2 agonists that reduce sympathetic output may be effective adjunct treatment modalities without suppressing respiratory drive. Some older studies using clonidine demonstrated possible benefit. There are also several case reports and a small case series using dexmedetomidine (a parenteral alpha-2 agonist). Three larger case series were published in 2012 evaluating dexmedetomidine in this role. FDA-approved dosing is 0.2-0.7 mcg/kg/hr as a continuous infusion. [1]

The Data
  • A retrospective case series of 10 ICU patients demonstrated safety of dexmedetomidine for ethanol withdrawal. Only 3 patients needed intubation, less benzodiazepines were required, and heart rate and blood pressure were decreased up to 10%. Maximum dexmedetomidine dose used was 1.2 mcg/kg/hr. [2]
  • A prospective case series of 18 ICU patients further demonstrated safety of dexmedetomidine for ethanol withdrawal when administered for a mean 24 hours. No patients required intubation. Time to resolution of alchohol withdrawal was 3.8 days, with and ICU length of stay 7.1 days, and hospital length of stay 12.1 days. Maximum dexmedetomidine dose used was 1.5 mcg/kg/hr. [3]
  • A retrospective case series of 20 ICU patients demonstrated a 62% reduction in benzodiazepine dosing after initiation of dexmedetomidine and a 21% reduction in alcohol withdrawal severity score. Only one patient required intubation. Dexmedetomidine was stopped in one patient who had two 9-second asystolic pauses noted on telemetry. [4]
  • Key Points
    While none of these studies had a comparison group, there are a few take home points worth mentioning:
  • Dexmedetomidine may be a useful adjunct to benzodiazepines for ethanol withdrawal patients (in the ED or ICU).
  • Reduced benzodiazepine requirements have been observed.
  • Dexmedetomidine does not suppress the respiratory drive and can be administered to non-intubated patients.
  • Bradycardia and possibly hypotension are the major adverse effects with dexmedetomidine use.
  • Translation to Clinical Care
    Some are using adjunct alpha-2 agonists with success (with benzodiazepines).
    @ arikestler @ critcareguys @ cliffreid @ emcrit @ pharmertoxguy Yes sir, I do! No bolus & titrate up. Less overall BDZ & res depress...
    — Haney Mallemat (@CriticalCareNow) December 28, 2012

    MT @ arikestler : Who uses dexmedetomidine 4 EtOH wthdrwl @ critcareguys @ criticalcarenow @ cliffreid @ emcrit @ pharmertoxguy Have used clonidine
    — Cliff Reid (@cliffreid) December 29, 2012

    Many institutions utilize nurse-driven alcohol withdrawal scales allowing them the autonomy to give patients symptom-triggered benzodiazepine therapy based on an objective score. ED nurses may not be as familiar with proper titration of dexmedetomidine, particularly in non-intubated patients. It may be prudent to have guidelines in place to ensure safe administration and good patient outcomes.

    [1] Muzyk AJ, Fowler JA, Norwood DK, et al. Role of alpha-2 agonists in the treatment of acute alcohol withdrawal. Ann Pharmacother 2011;45:649-57. [ PMID 21521867 ]

    [2] DeMuro JP, Botros DG, Wirkowski E, et al. Use of dexmedetomidine for the treatment of alcohol withdrawal syndrome in critically ill patients: a retrospective case series. J Anesth 2012;26(4):601-5. [ PMID 22584816 ]

    [3] Tolonen J, Rossinen J, Alho H, et al. Dexmedetomidine in addition to benzodiazepine-based sedation in patients with alcohol withdrawal delirium. Eur J Emerg Med 2012 [Epub ahead of print]. [ PMID 23247391 ]

    [4] Rayner SG, Weinert CR, Peng H, et al. Dexmedetomidine as adjunct treatment for severe alcohol withdrawal in the ICU. Ann Intensive Care 2012;2(1):12. [ PMID 22620986 ]

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