31st January 2024

Management

The mainstay of treatment for delirium tremens are benzodiazepines; NICE guidance currently lists oral lorazepam as the first line interventional medication to offer, followed by haloperidol or IM lorazepam. Benzodiazepines restore the neurotransmitter imbalance described above by promoting upregulation of GABA receptors, facilitating decreased neural intracellular excitation.

Early intervention can prevent later more severe features such as seizures, and NICE guidance also recommends offering those at high risk of developing the condition a “medically assisted” withdrawal as part of reducing the risk of the condition occurring. The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) is a rating scale (10 items with a maximum score of 67 points) that can rate the severity of withdrawal from alcohol to support necessary treatment and intervention, e.g., administration of chlordiazepoxide if needed. A brief score explanation is as follows:

• Mild withdrawal = 10 or less points
• Moderate withdrawal = 11 to 15 points
• Severe withdrawal = 16 or more points

If Untreated, delirium tremens can lead to autonomic dysfunction, including hyperthermia, arrhythmias and, in severe cases, death. The delirium described may not always be solely due to alcohol cessation/reduction. Other coexisting causes can be present, e.g., electrolyte imbalances, and must also be explored as part of optimal management.