1,4-Butanediol (1,4-BD) is an industrial solvent that is metabolized to gamma-hydroxybutyrate (GHB), a gamma-aminobutyric acid agonist and central nervous system depressant. GHB and its analogues are popular drugs of abuse. Withdrawal from these agents is characterized by autonomic instability and altered mental status. We report a case of withdrawal from 1,4-BD lasting 6 days and complicated by new onset of seizures and rhabdomyolysis. In addition, we conducted a systematic review of the English literature pertaining to withdrawal from GHB, 1,4-BD and gamma-butyrolactone (GBL). Data collected from source articles included last use prior to symptom onset, clinical features on presentation, duration of symptoms and outcome. Twenty-seven studies with 57 episodes of withdrawal were included. Thirty-six cases (63%) involved GHB, 3 cases (5%) involved 1,4-BD and 18 (32%) involved GBL. The most common patient symptoms were tremor (67%), hallucinations (63%), tachycardia (63%) and insomnia (58%). Seizures and rhabdomyolysis each occurred in 7% of cases, but only 1 death occurred. Emergency physicians must consider withdrawal from these agents when patients present with clinical features suggestive of a sedative-hypnotic withdrawal syndrome.

All twenty-nine bipolar 1 patents who satisfied DSM-111 criteria following their first hospitalisation for mania and subsequently discontinued their prophylactic lithium after a mean of 29 ± 21 months were studied. Patients were classified into poor prognosis (relapsed within 3 months of discontinuation, n = 8) and good prognosis groups (relapsed after 3 months or did not relapse, n = 21). Poor prognosis patients were more likely to have been prescribed additional psychotropic medication in the previous year (P = 0.026) and had higher serum lithium levels immediately prior to lithium discontinuation (P = 0.0043). Recent additional psychotropic medication may indicate that the patient is at an increased risk of early relapse if lithium prophylaxis is being stopped for any reason. The increased risk for those patients with higher lithium levels suggest that gradual phased reductions would be prudent.