We present the case of a 36-year-old male with chronic alcoholism who suffered Delirium Tremens and other complications during hospital admission and who recovered thanks to treatment with benzodiazepines and antiepileptics using a cross tapering strategy.

Presentation of a case and review of the available literature on the pharmacological treatment of alcohol withdrawal.

A 36-year-old man was hospitalised for extensive dermatological lesions suggestive of Pellagra. He acknowledged a daily consumption of six litres of beer, was homeless and had a poor and unvaried diet. After 48 hours, the patient began to present hyperreflexia, disorientation and delusions of harm and was diagnosed with Delirium Tremens.

The case was managed jointly by Internal Medicine and Psychiatry. High doses of Chlorazepate (up to 400 mg daily), Tiapride (up to 600 mg daily) and Thiamine (300 mg daily) were prescribed. After 5 days of treatment, the patient started to improve but severe pain appeared in the lower limbs suggestive of alcoholic neuropathy. Gradually the treatment was replaced by Pregabalin (up to a dose of 1200 mg daily) which was effective in calming the late withdrawal and partially controlling the lower limb pain.

Benzodiazepines remain the first-line agent for severe withdrawal, while some antiepileptic drugs have proven useful in mild-moderate withdrawal and relapse prevention. Switching to antiepileptic drugs during follow-up should be considered because of the lower risk of dependence and respiratory depression, as well as the positive effects on the “kindling” phenomenon.

No significant relationships.

To evaluate the effectiveness and tolerability of brivaracetam (BRV) in a refractory epilepsy population in an outpatient clinical setting.

Retrospective medical information system review and self-report questionnaire for all patients treated with BRV until the end of 2017.

Thirty-eight patients were included, 73.7% female and mean age 36.2. The mean number of antiepileptic drugs (AEDs) for previous use was 8.9, and for current use was 2.5. Mean seizure frequency in the last 3 months was 12 per month. At 3, 6, 12, and 15 months, the 50% responder rates were 36.1%, 32%, 41.2%, and 45.5%, respectively. Patients took BRV for a median duration of 8.25 months, ranging from 7 days to 60 months. Retention rate was 75.0%, 72.0%, 59.2%, and 47.9% at 3, 6, 12, and 15 months, respectively. Overall, the main reasons for discontinuation were adverse events (AEs) (52.3%), lack of efficacy (35.3%), or both (11.8%). The rate of total AEs was 60.5% according to medical records and 85.7% according to questionnaire, including mostly tiredness, psychiatric, and memory complaints. Psychiatric side effects occurred in 31.6% according to medical records and 47.4% according to questionnaire results, which is higher than previously reported and persisted throughout the study period.

BRV appears to be a useful and safe add-on treatment, even in a very refractory group of patients. In this real-life clinical setting, psychiatric AEs were found at a higher rate than previously published.