HWN Suggests

“Don’t Set the Precedent”: Precedex for Alcohol Withdrawal

Alcohol withdrawal is treated mainly by giving benzodiazepines (or phenobarbital). These work by binding GABA receptors and inhibiting NMDA receptors—basically imitating ethanol’s effects. Given the side effects of these agents there has been some interest in using adjunct agents – like Precedex (dexmedetomidine) to help treat withdrawal.Importantly,.. Precedex should never be used alone in alcohol withdrawal. It’s mechanism of action doesn’t affect GABA or NMDA receptors – it doesn’t treat the underlying pathophysiology of the disorder. All it does is reduce the autonomic symptoms of withdrawal and reduces CIWA scores

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 Dexmedetomidine For Treatment of Alcohol Withdrawal

Dexmedetomidine can be used for alcohol withdrawal. Rayner showed 61% reduction in benzo dosing with adding Precedex and 20% reduction in AWS score. However, Crispo studied 61 nonintubated patients with AWS and showed that Dex had more adverse drug affects and similar intubation rates/length of stay compared to benzos.

Articles of Interest

A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion

Dexmedetomidine is an alpha2-adrenergic agonist. It is used as a sedative in intravenous form in general anesthesia in the ICU and for monitored anesthesia care. In alcohol withdrawal syndrome, it is used off-label, including as monotherapy. ASAM recommends use of dexmedetomidine as an adjunct to benzodiazepine therapy to control autonomic hyperactivity and anxiety when these symptoms are not well controlled by optimized dosing of benzodiazepines alone.

Beyond Benzodiazepines: Adjuncts for the Management of Alcohol Withdrawal in the ICU

Interestingly, the dexmedetomidine group had significantly longer ICU LOS, cumulative benzodiazepine requirements, and use of restraints. The need for mechanical ventilation and incidence of seizures also were higher in the dexmedetomidine group, athough this was not significant. Given the retrospective nature and lack of protocolized dexmedetomidine use in AWS, it is difficult to determine if there were patient characteristics that may have contributed to increased ICU LOS, need for mechanical ventilation, and increased benzodiazepine use in the dexmedetomidine group.

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

Dexmedetomidine may be a useful adjunct to benzodiazepines for ethanol withdrawal patients (in the ED or ICU).

Dexmedetomidine...Better Than (Just) Benzos?

While BDZ are effective in the treatment of AWS, some patients may require very high doses of BDZ to control symptoms (tachycardia, hypertension, diaphoresis, etc.); unfortunately, high-doses of BDZ may lead to suppression of the respiratory drive and endotracheal intubation. Dexmedetomidine (DEX) is a sedative agent that is an intravenous alpha2-agonist (it's like clonidine); it reduces sympathetic outflow from the central nervous system and it may help treat withdrawal syndromes. The major benefit of DEX is that it does not suppress the respiratory drive, thus intubation is not required.

How should dexmedetomidine be used in severe alcohol withdrawal?

I remain concerned that when dexmedetomidine is added to a patient in alcohol withdrawal, symptom-triggered dosing of benzodiazepines comes to a halt. To attempt to counter this, I ask for a scheduled benzodiazepine regimen to be added.

Resistant Etoh Withdrawal - Try Dexmedetomidine (Precedex)

If you are treating an alcohol withdrawal patient and benzodiazepines are not working, try dexmedetomidine (precedex). This centrally acting alpha-2 agonist was utilized in 18 ICU patients and was shown to be safe. Average diazepam dose was 193 mg IV and lorazepam dose was 9 mg IV in these patients. Haloperidol was utilized in 3 of these patients which is not an effective therapy for alcohol withdrawal (could worsen due to QT prolongation, decrease seizure threshold and anticholinergic effects).

The Use of Dexmedetomidine in the Emergency Department: A Cohort Study

Dexmedetomidine is most commonly administered in the ED for patients with acute respiratory failure. Adverse events are relatively common, yet DEX is discontinued comparatively infrequently due to adverse events. Our results suggest that DEX could be a viable option for analgesia, anxiolysis, and sedation in ED patients.

Treatment of Alcohol Withdrawal Syndrome with and without Dexmedetomidine

Dexmedetomidine initiation was associated with a reduction in short-term alcohol withdrawal symptoms in patients in the intensive care unit, with only a few patients experiencing adverse events. However, its use was also associated with longer hospitalizations. Further research is necessary to evaluate whether dexmedetomidine is efficacious or cost-effective in severe alcohol withdrawal.

Update: What evidence is available on the off-label use of dexmedetomidine for alcohol withdrawal syndrome?

Overall, evidence supporting use of dexmedetomidine as an adjunct agent for alcohol withdrawal symptoms is limited to low quality data of mostly retrospective studies and 2 randomized controlled trials. Although there are limited data supporting its use, the 2020 ASAM guideline recommends its use as an adjunct to benzodiazepine therapy for hyperactivity and anxiety symptoms that are not controlled with benzodiazepines alone, and for patients in the ICU experiencing resistant alcohol withdrawal symptoms.