Propofol in Alcohol Withdrawal

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November 8, 2017 by Casey Carr

By: Casey Carr


Pathophysiology of Alcohol Withdrawal:

  • Prolonged and frequent consumption of alcohol (GABA agonist) results in the down regulation of GABA receptors, and upregulation of glutamate to maintain homeostatic level of excitation
  • Removal of alcohol results in over activation of NMDA (glutamate/excitatory receptors) receptors, and an inability to achieve a compensatory response with GABA given the prolonged down regulation of GABA receptors

Treatment strategy

  • The classic treatment principle of alcohol withdrawal treatment is replacing the loss of alcohol with GABA agonists, specifically benzodiazepines– the use treatment strategy in using benzodiazepines though varies (bolus versus continuous, symptom triggered, fixed tapered dosing) and with mixed evidence

Physiology of propofol

  • Enhances the activity of GABA by interacting with the GABA A receptor complex (it may also interact with other neurotransmitters)
  • Decreases the rate of dissociation of GABA from the GABA receptor, resulting in the increased duration of GABA activated opening of the chloride channel – it may also antagonize NMDA receptors as well

Evidence

  • There is no RCT comparing benzodiazepines to propofol – the vast majority of literature is on propofol in patients with alcohol withdrawal refractory to benzodiazepines
  • In a retrospective chart review, Sohraby et al (Annals of Pharmacotherapy, 2014) demonstrated no difference in mechanical ventilation needs, ICU stay, mortality, or benzodiazepine dose in patients with alcohol withdrawal syndrome using propofol versus benzodiazepine alone – however there was a trend towards less benzodiazepine use in the propofol containing regiment
  • In a systematic review of propofol in alcohol withdrawal syndrome, Brotherton et al (Pharmacotherapy, 2016) found that patients with alcohol withdrawal syndrome on propofol had longer mechanical ventilation requirement and ICU length of stay. When compared to Precidex, propofol had increased incidence of hypotension and intubation, while Precidex had increased rates of bradycardia – both had similar benzodiazepine sparing results

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