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 delirium tremens  

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in the emergency room you asked to assess a man with alcoholic cirrhosis and recent alcohol cessation.He is agitated,confused and make a presumptive diagnosis of delirium tremens.what is the best treatment for his condition?
1) diazepam(valium)
2) nitrazepam(nitrazedon)
3) chlordiazepoxide(librium)
4) lorazepam(ativan)
5) clonazepam(rivotril)




why not lorazpam? can anyone give explanation.


dr in trouble,i agree with all of your explanation,but in cirrhosis patient are they safe?? because diazepam and chlordiazepoxide produce active metabolites. thanks


then whats the answer diazepam or chlordiazepoxide?


I don't think its Chlordiazepoxide . This is what i found :

Chlordiazepoxide should be administered cautiously to patients with severe hepatic disese because the elimination half-life of the drug can be prolonged, possibly resulting in toxicity. The liver is utilized for metabolism of chlordiazepoxide. Patients with hepatic disease should receive reduced initial dosages and be closely monitored for tolerability. Additionally, chlordiazepoxide metabolites may accumulate leading to severe and prolonged stupor in patients with cirrhosis or hepatitis. (Drug Monogram)

I think , answer should be Lorazepam (short acting ) .Benzodiazepines with short half-lives are especially useful for patients with serious liver impairment or evidence of preexisting encephalopathy or brain damage, but result in rapidly changing drug blood levels and must be given every 4 h to avoid abrupt fluctuations in blood levels that may increase the risk for seizures. Therefore, most clinicians use drugs with longer half-lives, such as diazepam or chlordiazepoxide, administering enough drug on day 1 to alleviate most of the symptoms of withdrawal (e.g., the tremor and elevated pulse) and then decreasing the dose by 20% on successive days over a period of 3 to 5 days. (Harrison)


DOC if liver is fine ........diazepam or clordiazpoxide

if liver has problem ..........oxazepam or lorazepam

so answer here would be lorazepam


that still leaves a choice between 2 possibles. So difficult to exclude diazepam.


Benzodiazepines are considered the drugs of choice for the management of all stages of the alcohol withdrawal syndrome, including DTs. Not only do they have a high margin of safety, but also prospective randomized clinical trials have demonstrated that benzodiazepines are very effective in treating the symptoms and signs of alcohol withdrawal and in decreasing the incidence of seizures and DTs. The longer-acting benzodiazepines, such as chlordiazepoxide and diazepam, appear to be more effective at preventing the serious complications of seizures and DTs than shorter-acting benzodiazepines such as alprazolam and oxazepam. Most experts recommend that intermittent IV bolus dosing of diazepam or lorazepam is the treatment of choice for drug therapy of DTs.

Intravenous lorazepam rather than diazepam has been successfully used and may be preferable in the elderly or in those with severe liver disease.


"may be preferable" is a long shot from MCQ principles. My impression: not a good question. Where does it come from?


I can recommend a reputable pharmacy - I recieved my pills within one week of ordering them.

Edited by teresa5454 on Feb 07, 2016 - 7:33 AM

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