Recommendations for research

In 2010, the guideline committee made the following recommendations for research. The committee's full set of recommendations for research is detailed in the full guideline.

1 Admission to hospital for acute alcohol withdrawal

What is the clinical and cost effectiveness of admitting people who attend hospital in mild or moderate acute alcohol withdrawal for unplanned medically assisted alcohol withdrawal compared with no admission and a planned medically assisted alcohol withdrawal with regard to the outcome of long-term abstinence?

Why this is important

People presenting at a hospital who are at risk of or have alcohol withdrawal seizures or delirium tremens need admission for medical management. People with milder withdrawal are not usually admitted, but given advice and provided with information regarding local outpatient alcohol addiction services. One of the concerns with this model is that the opportunity for intervention may be lost and that many of these people may never contact addiction services. Given that abstinence is the goal, it may be that admission for these people maximises the likelihood of achieving this goal. The concerns with admission are that it is costly, the patients may not be motivated and there has been no opportunity for psychological input prior to the medically assisted withdrawal from alcohol.

The research should aim to compare the two models of treatment with regard to the primary goal of abstinence. Health economic analysis should aim to determine the cost effectiveness of each approach. [2010]

2 Dosing regimens for acute alcohol withdrawal

What are the safety and efficacy of symptom-triggered, fixed-dosing and front‑loading regimens for the management of acute alcohol withdrawal?

Why this is important

Traditionally, acute alcohol withdrawal has been managed by administering medication, typically benzodiazepines, according to a predetermined tapered-dosing schedule over a specified number of days (with the option for additional doses for breakthrough symptoms). This is called fixed‑dosing. In contrast, medication can be administered in response to a person's individual signs and symptoms (symptom‑triggered) or by giving an initial 'loading' dose (front-loading) in conjunction with a symptom‑triggered or 'as required' regimen.

The safety and efficacy of symptom-triggered or front-loading regimens in comparison to the 'traditional' fixed-dose regimen needs to be established in patients admitted to acute hospital settings who undergo unplanned acute alcohol withdrawal. Staff and patients' experiences in conjunction with objective measures of acute alcohol withdrawal need to be collected. [2010]

3 Drugs for the management of alcohol withdrawal

What is the efficacy and cost effectiveness of clomethiazole compared with chlordiazepoxide or carbamazepine or benzodiazepines for the treatment of acute alcohol withdrawal with regard to the outcomes of withdrawal severity, risk of seizures, risk of delirium tremens, length of treatment and patient satisfaction?

Why this is important

Clomethiazole has powerful, short-acting, sedative, tranquilising and anticonvulsant properties which are mediated through an indirect effect on gamma-aminobutyric acid (GABA) receptors in the brain. It has fallen out of favour in many units for the management of acute alcohol withdrawal because of reports of dependence and concerns regarding over-sedation. These have been problems in the outpatient use of clomethiazole, but it has now been restricted to the inpatient setting, where clomethiazole may be of great value.

There are limited studies comparing clomethiazole with other agents. As such, an appropriately powered study comparing clomethiazole to chlordiazepoxide or carbamazepine or benzodiazepines with regard to the outcomes described above would help to define the role of this potentially very useful drug. [2010]

4 Assessment and monitoring

What is the clinical and cost effectiveness of interventions delivered in an acute hospital setting by an alcohol specialist nurse compared with those managed through acute hospital setting with no input from a specialist nurse?

Why this is important

Alcohol-related problems are an important public health problem in the UK. Many patients present to acute services and are managed according to local pharmacotherapeutic regimens. Coordination of the management of the acute withdrawal episode with the long-term management of the patient can be complex. Prevention of Wernicke's encephalopathy, assessment for liver and extra-hepatic disease, therapies targetting alcohol addiction and the long-term management of the patient's physical, mental and social wellbeing are all components of the care. It is considered that better management during the hospital admission may lead to better outcomes with regard to long-term abstinence and health. Studies investigating the impact of an alcohol specialist nurse on these outcomes are required. [2010]

5 Wernicke's encephalopathy

What is the clinical and cost effectiveness of the use of parenteral versus oral thiamine in preventing the first onset of Wernicke's encephalopathy in people undergoing medically assisted alcohol withdrawal?

Why this is important

Wernicke's encephalopathy has a devastating effect on the sufferer and can occur when people are withdrawing from alcohol. It is thought to be caused by a lack of thiamine due to poor diet and/or absorption at a time of increased requirement for the vitamin (for cerebral functions in particular), although little is known about the mechanisms involved. There is some theoretical and trial evidence to suggest that parenteral replacement elevates blood levels more quickly than oral replacement, however it is not known if this is clinically significant, and there is no convincing clinical evidence to suggest which route and dose of thiamine is most effective at preventing Wernicke's encephalopathy. This is important as parenteral dosing uses additional resources, is unpleasant for the patient and has a very small risk of anaphylaxis. Having a placebo arm is probably not acceptable, given the risks of significant brain damage. [2010]

  • National Institute for Health and Care Excellence (NICE)