Management of alcohol withdrawal syndrome in patients with coexistent alcohol-related liver disease

Background and aims Treatment of alcohol withdrawal syndrome (AWS) is challenging, especially in those with alcohol-related liver disease (ArLD). Guidelines suggest using shorter-acting benzodiazepines (BZDs) but clinical evidence is sparse. We assessed the management of AWS using the Glasgow Modified Alcohol Withdrawal Scale (GMAWS), with a symptom-triggered treatment (STT) approach using lorazepam in ArLD patients. Method Three groups of patients were identified: group 1: patients without ArLD with AWS; group 2: ArLD patients with AWS and group 3: ArLD patients without AWS. BZD use in the first 48 hours of admission was calculated, and alcohol use disorder was assessed with the Fast Alcohol Screening Tool (FAST). Results Of 613 hospital episodes, 232 were in group 1, 174 in group 2 and 207 in group 3. Compared with group 1, group 2 patients had lower FAST scores (14 (13, 15) cf 15 (14, 16); p=0.036), initial GMAWS (0 (0, 0) cf 2 (1, 2); p<0.0001) and less BZD prescribed (30 (20, 42) cf 30 (20, 42) mg; p<0.0001). STT (83% cf 48%: p<0.0001) and lorazepam (79% cf 22%: p<0.0001) were more common in group 2 patients. AWS treatment was not associated with a worse 180-day survival in ArLD patients (91.3% in group 2 and 80.2% in group 3). Conclusion Patients managed for AWS without ArLD received greater amounts of BZDs compared with those with both AWS and ArLD. There was no evidence of a survival disadvantage for those with ArLD managed for AWS. An STT approach favouring lorazepam for the management of AWS in ArLD was effective using the GMAWS guidance.