We would like to commend Mayo-Smith et al1 for their attempt to define practice guidelines for delirium tremens, a potentially lethal and commonly mistreated condition. We are concerned, however, that the authors do not clearly recommend intravenous benzodiazepines as the sedative-hypnotic of choice despite sound pharmacological rationale. The alcohol withdrawal results from reduced inhibition from GABAA receptors and excitation from glutamate (N-methyl-D-aspartate) receptors. Benzodiazepines, barbiturates, and other GABAergic agents are effective, probably owing to cross-tolerance with ethanol at the GABAA receptor.2 The use of titrated intravenous benzodiazepines usually leads to rapid control of these critically ill patients. Furthermore, we believe that the use of β-blockers, clonidine, and neuroleptics merely reduces the sympathetic symptoms of inadequately sedated patients without treating the underlying cause or improving outcome. In addition, experimental and clinical evidence contraindicate neuroleptics.2,3 Treatment protocols that emphasize loading doses of diazepam and symptom-triggered treatment, along with continuous monitoring, lead to a more rapid and safe detoxification.4,5
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