UMEM Educational Pearls

Title: Ketamine for Alcohol Withdrawal?

Keywords: ketamine, alcohol withdrawal, ethanol (PubMed Search)

Posted: 4/10/2015 by Bryan Hayes, PharmD (Updated: 5/7/2015)
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Background

In addition to the down regulation of GABA receptors in chronic ethanol users, there is an upregulation in NMDA receptor subtypes. Although the pathophysiology is much more complex, when ethanol abstinence occurs, there is a shortage of GABA-mediated CNS inhibition and a surplus of glutamate-mediated CNS excitation. If GABA agonists are the mainstay of treatment, why not also target the NMDA receptor? Enter ketamine.

The Data

Only one study exists and was published recently.

Retrospective review of 23 adult patients administered ketamine specifically for management of AWS.
Mean time to initiation of ketamine from first treatment of AWS, and total duration of therapy were 33.6 and 55.8 hours, respectively.
Mean initial infusion dose and median total infusion rate were 0.21 and 0.20 mg/kg/h, respectively.
No change in sedation or alcohol withdrawal scores within 6 hours of ketamine initiation.
Median change in benzodiazepine requirements at 12 and 24 hours post-ketamine initiation were -40.0 and -13.3 mg, respectively.
One documented adverse reaction of oversedation, requiring dose reduction.
Authors concluded that ketamine appears to reduce benzodiazepine requirements and is well tolerated at low doses.

Application to Clinical Practice

While the dexmedetomidine studies should not be using reduction in benzodiazepine requirements as an endpoint, it may be acceptable for ketamine since it actually works on the underlying pathophysiology. More studies are needed but it's good to see we’re starting to look at it.

References

Wong A, et al. Evaluation of adjunctive ketamine to benzodiazepines for management of alcohol withdrawal syndrome. Ann Pharmacother 2015;49(1):14-9. [PMID 25325907]

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