Benzodiazepine Treatment and Hospital Course of Medical Inpatients With Alcohol Withdrawal Syndrome in the Veterans Health Administration

OBJECTIVE: To describe initial benzodiazepine dosing strategies and factors associated with variation in benzodiazepine dosing in a national cohort of hospitalized patients with alcohol withdrawal syndrome (AWS). PATIENTS AND METHODS: This cross-sectional study included adult patients with AWS admitted to medical services and treated with benzodiazepines at 93 Veterans Health Administration hospitals in 2013. Treatment was categorized by initial benzodiazepine dosing strategy—fixed-dose, symptom-triggered, or front-loading. Associations with patient characteristics, facility, and cumulative benzodiazepine exposure, intensive care, and intubation were evaluated. RESULTS: Among 6938 medical inpatients with AWS, 2909 (41.9%), 2829 (40.8%), and 1200 (17.3%) received treatment with symptom-triggered, fixed-dose, and front-loading benzodiazepines, respectively. The magnitude of differences in initial treatment associated with patient characteristics was small compared with differences associated with the predominant practice at a facility. Compared with fixed-dose therapy, symptom-triggered therapy was associated with higher cumulative benzodiazepine exposure (mean, 208-mg vs 182-mg diazepam equivalents) and higher probability of intensive care and intubation (28.2% vs 21.3% and 4.8% vs 3.5%, respectively). CONCLUSION: This study revealed that real-world AWS treatment of medical inpatients was often inconsistent with published guidelines recommending symptom-triggered long-acting benzodiazepines for AWS. The facility where a patient was hospitalized was associated with marked treatment variation. In contrast to prior randomized controlled trials conducted in specialized detoxification units, hospitalized patients who received symptom-triggered therapy in this study had greater cumulative benzodiazepine exposure and higher probability of intensive care and intubation than those receiving fixed-dose therapy.