Diazepam May Not Add to Symptom-Titrated Midazolam/Lorazepam for Alcohol Withdrawal Syndrome

Objective: To determine whether diazepam, administered with symptomtriggered regimes, improves outcomes of critically ill patient with alcohol withdrawal syndrome (AWS). Design: Retrospective cohort syndrome. Setting: Intensive care units of a community teaching hospital. Patients: Admitted to ICU between January 2014 and December 2015 with a primary diagnosis of AWS. Measurements & results: Demographics, physiologic variables, treatments and outcomes are compared for patients receiving versus not receiving scheduled diazepam plus symptom-triggered lorazepam or midazolam. 67 patients who received symptom-titrated benzodiazepine averaged 48.9 ± (SE) 1.4 years and APACHE II 2.7 ± 0.3; 20 were female. Over the course of admission, patients received an average of 130 ± 26 mg LE, i.e., 18.7 ± 2.0 mg LE/day over mean LOS 7.8 days. The use of 0, ≤ 20 mg and ≤ 40 mg diazepam were associated with significantly less lorazepam equivalents (65 vs. 159 mg, P=0.02; 60 vs. 185 mg, P=0.008; 64 vs. 210 mg, P=0.01). Those receiving 100 mg or more of diazepam received far more lorazepam equivalents (252 vs. 66 mg, P=0.01). There was no difference in hospital length of stay for patients receiving diazepam vs. no diazepam. Four of 21 patients receiving no diazepam were intubated, compared to 6 of 46 who received diazepam (NS), a relationship that persisted across strata of diazepam doses. Because intravenous diazepam is substantially more expensive in our hospital (midaz $0.15/mg, diaz $2.07/mg, loraz $0.27/mg), diazepam regimens raised costs substantially across strata of administered doses. Conclusion: These data do not support that scheduled diazepam complements effectiveness of symptom-titrated benzodiazepine administration for AWS.