Carbamazepine effective for alcohol withdrawal - Patient-Oriented Evidence that Matters - Brief Article

Journal of Family Practice, Sept, 2002 by Sharon See

Malcolm R, Myrick H. Roberts J, Wang W, Anton RF, Ballenger JC. The effects of carbamazepine and lorazepam on single versus multiple previous alcohol withdrawals in an outpatient randomized trial. J Gen Intern Med 2002: 17:349-55.

* BACKGROUND Outpatient management of symptoms from acute alcohol withdrawal usually includes a tapering regimen of a benzodiazepine such as lorazepam. Benzodiazepine use is usually limited, however, by the potential for medication abuse and side effects such as central nervous system impairment. Because studies have demonstrated that carbamazepine can be effective for the treatment of alcohol withdrawal symptoms, this study compared the effectiveness of carbamazepine with that of lorazepam.

* POPULATION STUDIED The 136 patients were self-referred and fulfilled Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria for alcohol dependence and alcohol withdrawal. Patients lived within 50 miles of the study site, and had an admission blood alcohol level < 0.1 g/dL, a Mini Mental State Examination score of [greater than or equal to] 26, and an admission score on the Clinical Institute Withdrawal Assessment-Alcohol, revised (CIWA-Ar) [greater than or equal to] 10 out of a possible score of 20. Patients were excluded if they had substance abuse syndromes other than alcohol dependence, nicotine dependence, or cannabis abuse; major Axis I psychiatric disorder; used benzodiazcpines, beta-blockers, calcium channel blockers, or antipsychotic agents within the past 30 days; a history of head injury; neurologic illness; or grossly abnormal laboratory values.

* STUDY DESIGN AND VALIDITY This was a randomized double-blind trial comparing 2 different treatments for alcohol withdrawal. Allocation to treatment group was concealed from enrolling physicians. The patients received a 5-day taper of either lorazepam 6-8 mg tapered to 2 mg or carbamazepine 600-800 mg tapered to 200 mg. Withdrawal symptoms were measured using a validated CIWA-Ar tool. Patients also completed a daily drinking log to assess alcohol use prior to, during, and 7 days after study completion. The study evaluated 89 patients after the treatment period for number of drinks taken per day.

This well-done study had several limitations. This study relied on self referral by patients who reported previous withdrawal episodes. Most patients were white middle aged men, and the results may not be the same in other populations.

* OUTCOMES MEASURED Alcohol withdrawal symptoms and posttreatment alcohol use measured by the CIWA-Ar scale were the primary outcomes. Side effects were reported as a secondary outcome.

* RESULTS Both drugs were equally effective in reducing alcohol withdrawal symptoms. Over time, alcohol withdrawal symptoms were more likely to occur with lorazepam treatment (P = .007). After treatment, relapsing patients receiving carbamazepine had fewer drinks per day than those receiving lorazepam (1 vs 3; P = .003). Effectiveness varied based on whether patients had attempted alcohol detoxification in the past. Of the patients who reported prior multiple detoxifications, those receiving carbamazepine drank less than 1 drink per day as compared with 5 drinks per day in the lorazepam treated group (P = .004). The overall frequency of side effects was the same for both groups; however, clinicians recorded dizziness and incoordination in more patients on lorazepam than carbainazepine (22.7% vs 6.9%; P = .02). Pruritus occured more often in the carbamazepine group than the lorazepam group (18.9% vs 1.3%; P = .004).

RECOMMENDATIONS FOR CLINICAL PRACTICE

Carbamazepine is an effective alternative to benzodiazepines for the outpatient treatment of alcoholic withdrawal symptoms. Carbamazepine appears to be particularly effective for patients in whom detoxification failed in the past.

Sharon See, PharmD
St. John's University College of Pharmacy
and Allied Health Professions
Jamaica, New York
E-mail: sees@stjohns.edu

Each month, the POEMs editorial team reviews more than 90 journals of interest to primary care physicians, and identifies articles you need to know about to stay" up to date. We call these articles POEMs (Patient-Oriented Evidence that Matters) because they address common primary care problems, report outcomes that matter to patients, and, if valid, require us to change the way we practice. The collected reviews are available online at www.jfponline.com.