Critical Care Medicine

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Critical Care Medicine:
doi: 10.1097/CCM.0000000000000141
Clinical Investigations

A Randomized, Double-Blind, Placebo-Controlled Dose Range Study of Dexmedetomidine as Adjunctive Therapy for Alcohol Withdrawal*

Mueller, Scott W. PharmD1; Preslaski, Candice R. PharmD2; Kiser, Tyree H. PharmD, FCCP, FCCM1; Fish, Douglas N. PharmD, FCCP, FCCM1; Lavelle, James C. MD3; Malkoski, Stephen P. MD, PhD3; MacLaren, Robert PharmD, MPH, FCCP, FCCM1

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Objectives: To evaluate dexmedetomidine as adjunctive therapy to lorazepam for severe alcohol withdrawal.

Design: Prospective, randomized, double-blind, placebo-controlled trial.

Setting: Single center; medical ICU.

Patients: Twenty-four adult patients with a Clinical Institute Withdrawal Assessment score greater than or equal to 15 despite greater than or equal to 16 mg of lorazepam over a 4-hour period.

Interventions: Patients received a symptom-triggered Clinical Institute Withdrawal Assessment protocol with lorazepam and were randomized to dexmedetomidine 1.2 μg/kg/hr (high dose), 0.4 μg/kg/hr (low dose), or placebo as adjunctive therapy for up to 5 days or resolution of withdrawal symptoms.

Measurement and Main Results: High-dose and low-dose groups were combined as a single dexmedetomidine group for primary analysis with secondary analysis exploring a dose-response relationship. The difference in 24-hour lorazepam requirements after versus before study drug was greater in the dexmedetomidine group compared with the placebo group (–56 mg vs –8 mg, p = 0.037). Median differences were similar for high dose and low dose. The 7-day cumulative lorazepam requirements were not statistically different between dexmedetomidine and placebo (159 mg vs 181 mg). Clinical Institute Withdrawal Assessment or Riker sedation-agitation scale scores representing severe agitation (13% vs 25%) or moderate agitation (27% vs 22%) within 24 hours of initiating study drug were similar for dexmedetomidine and placebo groups, respectively. Bradycardia occurred more frequently in the dexmedetomidine group versus placebo group (25% vs 0%, p = not significant), with the majority of bradycardia occurring in the high-dose group (37.5%). Study drug rate adjustments occurred more often in the dexmedetomidine group compared with the placebo group (50% vs 0%, p = 0.02). Neither endotracheal intubation nor seizure occurred in any group while on study drug.

Conclusions: Adjunctive dexmedetomidine for severe alcohol withdrawal maintains symptom control and reduces lorazepam exposure in the short term, but not long term, when using a symptom-triggered protocol. Monitoring for bradycardia is needed with dexmedetomidine but the occurrence may be lessened with low dose. Further study is needed to evaluate the clinical impact of dexmedetomidine.

© 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins

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