Chlormethiazole as a hypnotic in elderly patients: A systematic review and meta-analysis

The study objective was to estimate the efficacy and safety of chlormethiazole in older adults experiencing insomnia (sleep disorder). We therefore systematically searched Medline, Scopus, the Cochrane Library, PsycINFO, Ovid, ZB MED and PMC through December 2021 for randomized-controlled trials including patients > 60 years old with insomnia treated with chlormethiazole. Standardized mean differences or odds ratios with 95% confidence intervals were calculated for the main outcome parameters: sleep duration, onset of sleep, quality of sleep, adverse events or drop-out rates compared with placebo and other drugs. Risk of bias was assessed using the Cochrane tool. Eight randomized-controlled trials with 424 patients were included. Chlormethiazole significantly increased the duration of sleep when compared with placebo (standardized mean difference = 0.61; 95% confidence interval = 0.11-1.11; p = 0.02). More patients receiving chlormethiazole had adequate quality of sleep than those receiving other drugs (odds ratio = 1.44; 95% confidence interval = 1.04-1.98; p = 0.03). No differences were found regarding the onset of sleep (standardized mean difference = 1.07; 95% confidence interval = 0.79-1.46; p = 0.65). Drop-out rates were significantly lower under chlormethiazole treatment when compared with other drugs (odds ratio = 0.51; 95% confidence interval = 0.26-0.99; p = 0.05) and did not differ from placebo treatment (odds ratio = 1.37; 95% confidence interval = 0.23-8.21; p = 0.73). Side-effects such as "hangover" and daytime drowsiness occurred less frequently during chlormethiazole treatment compared with other drugs in three out of four studies, but differences were not significant (odds ratio = 0.24; 95% confidence interval = 0.04-1.48; p = 0.12). In conclusion, chlormethiazole showed significant effects on the duration and the quality of sleep with better tolerability if compared with other drugs in older adults with insomnia.

Gamma aminobutyric acid (GABA) receptor agonists for acute stroke

BACKGROUND

Gamma aminobutyric acid (GABA) receptor agonists have been shown to have a neuroprotectant effect in reducing infarct size and improving functional outcome in animal models of cerebrovascular disease. However, the sedative effects of GABA receptor agonists have limited their wider application in people with acute stroke, due to the potential risk of stupor. This is an update of a Cochrane Review first published in 2013, and previously updated in 2014 and 2016.

OBJECTIVES

To determine the efficacy and safety of GABA receptor agonists in the treatment of acute stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (accessed May 2018), the Cochrane Central Register of Controlled Trials (CENTRAL) 2018, Issue 4 (accessed May 2018), MEDLINE (from 1949 to May 2018), Embase (from 1980 to May 2018), CINAHL (from 1982 to May 2018), AMED (from 1985 to May 2018), and 11 Chinese databases (accessed May 2018). In an effort to identify further published, unpublished, and ongoing trials we searched ongoing trial registers, reference lists, and relevant conference proceedings, and contacted authors and pharmaceutical companies.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) investigating GABA receptor agonists versus placebo for people with acute stroke (within 12 hours after stroke onset), with the primary outcomes of efficacy and safety.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the titles and abstracts of identified records, selected studies for inclusion, extracted eligible data, cross-checked the data for accuracy, and assessed the risk of bias. We used the GRADE approach to assess the quality of the evidence.

MAIN RESULTS

We included five trials with 3838 participants (acute ischemic or hemorrhagic stroke patients, 3758 analyzed). Most of the participants recruited had acute ischaemic stroke, with limited data available from participants with other stroke subtypes, including total anterior circulation syndrome (TACS). The methodological quality of the included trials was generally good, with an unclear risk for selection bias only. For death and dependency at three months, pooled results did not find a significant difference for chlormethiazole versus placebo (risk ratio (RR) 1.03, 95% confidence interval (CI) 0.96 to 1.11; four trials; 2909 participants; moderate-quality evidence) and for diazepam versus placebo (RR 0.94, 95% CI 0.82 to 1.07; one trial; 849 participants; moderate-quality evidence). The most frequent adverse events related to chlormethiazole were somnolence (RR 4.56, 95% CI 3.50 to 5.95; two trials; 2527 participants; moderate-quality evidence) and rhinitis (RR 4.75, 95% CI 2.67 to 8.46; two trials; 2527 participants; moderate-quality evidence).

AUTHORS' CONCLUSIONS

This review provides moderate-quality evidence that fails to support the use of GABA receptor agonists (chlormethiazole or diazepam) for the treatment of people with acute stroke. More well-designed RCTs with large samples of participants with total anterior circulation syndrome are required to determine if there are benefits for this subgroup. Somnolence and rhinitis are frequent adverse events related to chlormethiazole.

Gamma aminobutyric acid (GABA) receptor agonists for acute stroke

BACKGROUND

Gamma aminobutyric acid (GABA) receptor agonists have been shown to have a neuroprotectant effect in reducing infarct size and improving functional outcome in animal models of cerebrovascular disease. However, the sedative effects of GABA receptor agonists have limited their wider application in people with acute stroke, due to the potential risk of stupor. This is an update of a Cochrane review first published in 2013, and previously updated in 2014.

OBJECTIVES

To determine the efficacy and safety of GABA receptor agonists in the treatment of acute stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (accessed March 2016), the Cochrane Central Register of Controlled Trials (CENTRAL) 2016, Issue 3, part of the Cochrane Library (accessed March 2016), MEDLINE (from 1949 to March 2016), Embase (from 1980 to March 2016), CINAHL (from 1982 to March 2016), AMED (from 1985 to March 2016), and 11 Chinese databases (accessed March 2016). In an effort to identify further published, unpublished, and ongoing trials we searched ongoing trials registers, reference lists, and relevant conference proceedings, and contacted authors and pharmaceutical companies.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) investigating GABA receptor agonists versus placebo for people with acute stroke (within 12 hours after stroke onset), with the primary outcomes of efficacy and safety.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the titles and abstracts of identified records, selected studies for inclusion, extracted eligible data, cross-checked the data for accuracy, and assessed the risk of bias.

MAIN RESULTS

We included five trials with 3838 participants (3758 analyzed). The methodological quality of the included trials was generally good, with an unclear risk for selection bias only. Four trials (N = 2909) measured death and dependency at three months for chlormethiazole versus placebo; pooled results did not find a significant difference (risk ratio (RR) 1.03, 95% confidence interval (CI) 0.96 to 1.11). One trial (N = 849) measured this outcome for diazepam versus placebo (RR 0.94, 95% CI 0.82 to 1.07). The most frequent adverse events related to chlormethiazole were somnolence (RR 4.56, 95% CI 3.50 to 5.95; two trials; N = 2527) and rhinitis (RR 4.75, 95% CI 2.67 to 8.46; two trials; N = 2527).

AUTHORS' CONCLUSIONS

This review provides moderate-quality evidence that fails to support the use of GABA receptor agonists (chlormethiazole or diazepam) for the treatment of people with acute stroke. More well-designed RCTs with large samples of participants with total anterior circulation syndrome are required to determine if there are benefits for this subgroup. Somnolence and rhinitis are frequent adverse events related to chlormethiazole.

Gamma aminobutyric acid (GABA) receptor agonists for acute stroke

BACKGROUND

Gamma aminobutyric acid (GABA) receptor agonists have been shown to have a neuroprotectant effect in reducing infarct size and improving functional outcome in animal models of cerebral ischemia. However, the sedation effects of GABA receptor agonists have limited their wider application in acute stroke patients due to the potential risk of stupor.

OBJECTIVES

To determine the efficacy and safety of GABA receptor agonists in the treatment of acute stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (February 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 5), MEDLINE (1949 to June 2014), EMBASE (1980 to June 2014), CINAHL (1982 to June 2014), AMED (1985 to June 2014) and 11 Chinese databases (June 2014). In an effort to identify further published, unpublished and ongoing trials we searched ongoing trials registers, reference lists and relevant conference proceedings, and contacted authors and pharmaceutical companies.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) investigating GABA receptor agonists versus placebo for acute stroke patients (within 12 hours after stroke onset), with the outcomes of death or dependency, functional independence and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the titles and abstracts of identified records, selected studies for inclusion, extracted eligible data, cross-checked the data for accuracy and assessed the methodological quality.

MAIN RESULTS

We included five trials with 3838 patients. The methodological quality of the included trials was generally good, with low risk of bias. Four trials measured death and dependency at three months in chlormethiazole versus placebo without significant difference (risk ratio (RR) 1.03, 95% confidence interval (CI) 0.95 to 1.11). One trial measured this outcome between diazepam and placebo (RR 0.94, 95% CI 0.82 to 1.07). In the subgroup analysis of total anterior circulation syndrome (TACS), a higher percentage of functional independence was found in the chlormethiazole group (RR 1.33, 95% CI 1.09 to 1.64). The frequent adverse events related to chlormethiazole were somnolence (RR 4.56, 95% CI 3.50 to 5.95) and rhinitis (RR 4.75, 95% CI 2.67 to 8.46).

AUTHORS' CONCLUSIONS

This review does not provide the evidence to support the use of GABA receptor agonists (chlormethiazole or diazepam) for the treatment of patients with acute ischemic or hemorrhagic stroke. Chlormethiazole appeared to be beneficial in improving functional independence in patients with TACS according to the subgroup analysis, but this result must be interpreted with great caution. More well-designed RCTs with large samples of TACS would be required for further confirmation. However, somnolence and rhinitis are frequent adverse events related to chlormethiazole.

Gamma aminobutyric acid (GABA) receptor agonists for acute stroke

BACKGROUND

Gamma aminobutyric acid (GABA) receptor agonists have been shown to have a neuroprotectant effect in reducing infarct size and improving functional outcome in animal models of cerebral ischemia. However, the sedation effects of GABA receptor agonists have limited their wider application in acute stroke patients due to the potential risk of stupor.

OBJECTIVES

To determine the efficacy and safety of GABA receptor agonists in the treatment of acute stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (January 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 1), MEDLINE (1949 to March 2012), EMBASE (1980 to March 2012), CINAHL (1982 to March 2012), AMED (1985 to March 2012) and 11 Chinese databases (March 2012). In an effort to identify further published, unpublished and ongoing trials we searched ongoing trials registers, reference lists and relevant conference proceedings, and contacted authors and pharmaceutical companies.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) investigating GABA receptor agonists versus placebo for acute stroke patients (within 12 hours after stroke onset), with the outcomes of death or dependency, functional independence and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the titles and abstracts of identified records, selected studies for inclusion, extracted eligible data, cross-checked the data for accuracy and assessed the methodological quality.

MAIN RESULTS

We included five trials with 3838 patients. The methodological quality of the included trials was generally good, with low risk of bias. Four trials measured death and dependency at three months in chlormethiazole versus placebo without significant difference (risk ratio (RR) 1.03, 95% confidence interval (CI) 0.95 to 1.11). One trial measured this outcome between diazepam and placebo (RR 0.94, 95% CI 0.82 to 1.07). In the subgroup analysis of total anterior circulation syndrome (TACS), a higher percentage of functional independence was found in the chlormethiazole group (RR 1.33, 95% CI 1.09 to 1.64). The frequent adverse events related to chlormethiazole were somnolence (RR 4.56, 95% CI 3.50 to 5.95) and rhinitis (RR 4.75, 95% CI 2.67 to 8.46).

AUTHORS' CONCLUSIONS

This review does not provide the evidence to support the use of GABA receptor agonists (chlormethiazole or diazepam) for the treatment of patients with acute ischemic or hemorrhagic stroke. Chlormethiazole appeared to be beneficial in improving functional independence in patients with TACS according to the subgroup analysis, but this result must be interpreted with great caution. More well-designed RCTs with large samples of TACS would be required for further confirmation. However, somnolence and rhinitis are frequent adverse events related to chlormethiazole.

Alcohol withdrawal syndrome: how to predict, prevent, diagnose and treat it

(1) When people who are physically dependent on alcohol stop drinking, they experience an alcohol withdrawal syndrome. The symptoms generally resolve spontaneously within a week, but more severe forms may be associated with generalised seizures, hallucinations and delirium tremens, which can be fatal. (2) We carried out a literature review in order to obtain answers to the following questions: how to predict or rapidly diagnose a severe alcohol withdrawal syndrome; how to prevent and treat this syndrome; how to manage severe forms; and how to deal with the risk of vitamin B1 deficiency. (3) The main risk factors for severe withdrawal syndrome are: chronic heavy drinking; a history of generalised seizures; and a history of delirium tremens. (4) Anxiety, agitation, tremor, excessive sweating, altered consciousness and hallucinations are signs of a severe withdrawal syndrome. (5) Individual support and effective communication seem to reduce the risk of severe withdrawal syndrome. (6) Oral benzodiazepines are the best-assessed drugs for preventing a severe alcohol withdrawal syndrome, particularly the risk of seizures. When given for a maximum of 7 days, the adverse effects are usually mild. (7) Clinical trials of other antiepileptics suggest they are less effective than benzodiazepines, and their addition to benzodiazepine therapy offers no tangible advantage. (8) Betablockers increase the risk of hallucinations, and clonidine increases the risk of nightmares, and the efficacy of these two drugs is not well documented. Neuroleptics increase the risk of seizures. There are no convincing data to support the use of magnesium sulphate or meprobamate (the latter carries a risk of serious adverse effects). Acamprosate, naltrexone and disulfiram are not beneficial in alcohol withdrawal. (9) Gradual withdrawal, i.e. ingestion of decreasing amounts of alcohol, has not been compared with other methods but is generally not recommended. (10) There are no specific recommendations on hydration. Note that excessive water-sodium intake carries a risk of pulmonary oedema in patients with heart disease. (11) As vitamin B1 deficiency is frequent and can lead to serious complications in alcohol-dependent patients, oral vitamin B1 supplementation is widely recommended, despite the absence of comparative trials. High doses must be used to compensate for poor absorption. Intravenous administration is best if patients have very poor nutritional status or severe complications such as Gayet-Wernicke encephalopathy (a medical emergency), even though rare anaphylactic reactions have been reported after vitamin B1 injection. (12) Planned alcohol withdrawal in specialised hospital units has been extensively studied. Outpatient withdrawal may be more appropriate for patients who are at low risk of developing severe withdrawal syndrome. (13) A large proportion of alcohol-dependent patients were excluded from trials of withdrawal strategies. These include elderly patients, patients with serious psychiatric or somatic disorders, and patients who are also dependent on other substances. (14) An oral benzodiazepine is the best-assessed treatment for a single episode of generalised seizures or hallucinations during alcohol withdrawal. (15) In randomised comparative trials benzodiazepines were more effective than neuroleptics in preventing delirium-related mortality. Currently, with appropriate fluid-electrolyte support, continuous monitoring of vital signs, and respiratory support if necessary, the mortality rate for delirium tremens is under 3%. (16) In practice, patients who are attempting to stop drinking alcohol need close personal support and communication, and a reassuring environment, as well as regular monitoring for early signs of a withdrawal syndrome; the latter may require benzodiazepine therapy.

The effects of clomethiazole on polysomnographically recorded sleep in healthy subjects

Clomethiazole is widely used in European countries to treat alcohol withdrawal symptoms including delirium tremens. The current study aimed to explore the effects of clomethiazole on the sleep of healthy volunteers. We postulated both a hypnotic and a REM suppressive effect as well as the occurrence of a rebound phenomenon following three days of treatment with clomethiazole. The study group was composed of five men and five women. The probands were examined in the sleep laboratory throughout a course of seven nights. The first night was considered as the adaptation night and the second as the baseline night. Prior to nights 3 to 5, probands took 384 mg clomethiazole at 22 hours. The 6th and 7th nights served to record potential effects of medication discontinuation. The current study confirms the indication in the scientific literature with regard to hypnotic and REM-suppressive effects of clomethiazole, as well as a rebound phenomenon following discontinuation of the medication. The effect of clomethiazole on the sleep EEG was most obvious in the first half of the night. The analysis of the polysomnogram in terms of each half of the night gave no indication of a rebound phenomenon during the second half. The REM sleep-suppressing component of clomethiazole is of great interest in connection with its use in treating delirium tremens. The rebound phenomenon in healthy controls after only three days of medication at a relatively low dosage of clomethiazole underscores the need to administer it in doses individually tailored to the extent of the alcohol withdrawal syndrome in the individual patient.

Pharmacokinetics and sedative effects in healthy subjects and subjects with impaired liver function after continuous infusion of clomethiazole

OBJECTIVE

Clomethiazole is virtually completely eliminated by hepatic metabolism. This study was designed to assess the impact of liver impairment on its elimination and sedative effects.

METHODS

Eight patients with mild liver impairment (Child-Pugh grade A), eight patients with moderate/severe liver impairment (Child-Pugh grade B/C) and eight healthy subjects of similar age were given 68 mg/kg clomethiazole edisilate according to a 24-h infusion scheme aimed at producing minimum sedation as it was intended for clinical use in patients with stroke. Concentrations of clomethiazole and its active alpha-carbon hydroxylated metabolite NLA-715 were followed in plasma and urine for 96 h and 24 h, respectively. Sedation was monitored using a scale from 1 to 6.

RESULTS

The fraction excreted unchanged in urine was less than 0.2% for clomethiazole and less than 0.4% for NLA-715. Urine concentrations of clomethiazole were strongly correlated (r(2)=0.60) to plasma concentrations and approximately equal to unbound plasma concentrations. Plasma levels of NLA-715 increased steadily during the infusion, eventually reaching mean levels exceeding those of clomethiazole in all groups. Plasma clearance of clomethiazole in subjects with mildly impaired liver function was not statistically different from that of healthy controls (40 l/h vs 44 l/h). In subjects with moderate/severe liver impairment, there was a 50% reduction in clearance. Sedation was not observed except in two subjects in the Child-Pugh A group showing mild sedation.

CONCLUSION

The reduced clomethiazole clearance in patients with moderate/severe liver impairment seems to call for a reduction of clomethiazole dosage. However, sedation was not observed in this group at the investigated dose level.

Serum concentration of chlormethiazole and therapeutic effect in acute alcohol withdrawal syndrome: an open clinical trial

It was the aim of this study to find a relationship between the serum concentration of chlormethiazole and its therapeutic effect in acute alcohol withdrawal syndrome. As a secondary subject, the concentration of chlormethiazole was investigated in relation to variables of treatment and variables of physical status of patients. In an open clinical trial, the clinical status of patients was rated by the Mainz Alcohol Withdrawal Scale (MAWS) and the Delirium Rating Scale (DRS). Chlormethiazole concentration was measured by gas-liquid chromatography. Patients were dichotomized according to minimum values of MAWS and DRS after 2 days of treatment (good response and retarded or no response). Chlormethiazole concentration and dose per body weight and MAWS and DRS scores before treatment were compared by the Student t test and the Mann-Whitney test. The two groups were also analyzed by logistic regression with chlormethiazole concentration, MAWS and DRS score before treatment, age, gender, body weight, years of alcoholism, and dose per body weight as independent variables. Chlormethiazole concentration was analyzed by multiple regression with dose, age, gender, smoking, initial alcohol, body weight, and liver dysfunction as independent variables. Forty-three patients were included in the study. Twenty-four patients reached a minimum time of investigation of 2 days. The chlormethiazole concentration was in the range of 0.3 to 5.4 microg/mL at doses of 10 to 24 capsules/d (1 capsule = 192 mg chlormethiazole). As the main result, significantly increased chlormethiazole concentrations were found in patients with retarded or no response; however, in addition the DRS score before treatment and dose per body weight were increased. In addition, the final models of logistic regression contained only DRS score before treatment. As a secondary result, the final model of multiple regression revealed an increased chlormethiazole concentration with dose of chlormethiazole and concentration of alcohol in blood and a decreased chlormethiazole concentration with body weight. This was the first study to investigate the relationship between the chlormethiazole concentration and therapeutic effect in alcohol withdrawal. No robust relationship could be detected that could be separated from the control of treatment by clinical variables. Rather, a poor therapeutic outcome is mainly predicted by an increased initial severity of symptoms, and higher doses are applied in more severely ill patients. Thus, pharmacokinetic control of treatment is not recommended.

Clomethiazole Acute Stroke Study in ischemic stroke (CLASS-I): final results

BACKGROUND AND PURPOSE

A previous trial (the Clomethiazole Acute Stroke Study) generated the hypothesis that clomethiazole is effective in patients with a major ischemic stroke (total anterior circulation syndrome), and this was tested in the present study.

METHODS

A total of 1198 patients with major ischemic stroke and a combination of limb weakness, higher cortical dysfunction, and visual field deficits were randomly assigned to clomethiazole (68 mg/kg IV over 24 hours) or placebo. The study drug was initiated within 12 hours of symptom onset. Functional outcome and neurological recovery were assessed at days 7, 30, and 90, with the proportion of patients with a Barthel Index > or =60 at last follow-up as the primary outcome measure.

RESULTS

The patients were randomly assigned equally, and the two treatment groups were well matched for baseline characteristics, including stroke severity (mean National Institutes of Health Stroke Scale score 16.9+/-5.2). Ninety-six percent were classified as total anterior circulation syndrome. The proportion of patients reaching a Barthel Index score of > or =60 was 42% in the clomethiazole-treated group and 46% in the placebo-treated group (odds ratio, 0.81; 95% CI, 0.62 to 1.05; P=0.11). There was no evidence of efficacy on any secondary outcome variables (modified Rankin Score, National Institutes of Health Stroke Scale, Scandinavian Stroke Scale, and 30-day CT infarct volumes) compared with placebo. Subgroup analysis showed a similar lack of treatment effect in patients treated early (<6 hours) and in those treated later (6 to 12 hours). Somnolence was an expected pharmacological effect of clomethiazole, and this occurred during treatment as an adverse event in half of the patients randomly assigned to study drug.

CONCLUSIONS

The target population was selected, and sufficient drug was given to produce the expected pharmacological effect in the brain. Clomethiazole does not improve outcome in patients with major ischemic stroke.

GABA agonist: clomethiazole

Neuroprotective agents inhibit reactions in the brain ischaemic injury cascade which lead to neuronal death. Gamma-aminobutyric acid (GABA) is a naturally occurring inhibitory neurotransmitter that increases chloride influx into the neuron and counteracts the toxic effects of glutamate. Clomethiazole is a GABA(A) agonist, which causes membrane hyperpolarization, counteracting depolarization and the subsequent cascade of biochemical events that result in neuronal death. Promising results in animal models resulted in clinical trials conducted in humans. However, large randomized placebo controlled trials in Europe, Canada and North America did not show the superiority of clomethiazole over placebo that was seen in animal models.

Treatment of alcohol withdrawal: tiapride and carbamazepine versus clomethiazole. A pilot study

In Germany, clomethiazole (CLO) and benzodiazepines are predominantly used as therapeutic agents in the treatment of the alcohol withdrawal syndrome (AWS). These agents have disadvantages such as sedation, risk of respiratory insufficiency, and cardiovascular complications as well as addictive potential. Alternatively, it could be demonstrated that both tiapride (TIA) and carbamazepine (CBZ) are efficient in the treatment of AWS with less toxicity. However, they seem to be less effective in AWS than CLO as single agents. But no systematic comparison of the combination of TIA and CBZ against an established therapeutic standard can be found in the literature. Therefore, we compared the combination of TIA and CBZ with CLO in two open exploratory studies with matched samples. Outcome parameters were heart rate, blood pressure, complications, withdrawal symptoms (CIWA-Ar scale), and general clinical state (CGI scale). A retrospective evaluation of medical records (30 TIA+CBZ, 30 CLO) was followed by an open prospective study (40 TIA+CBZ, 40 CLO). Both studies revealed similar efficacy in terms of psychopathologic and vegetative symptoms. Vegetative recovery seems to be faster with TIA+CBZ. Results of this exploratory study have to be confirmed by a controlled double-blind study with severity of AWS as an experimental factor.

[Alcohol withdrawal syndrome and its treatment]

When alcoholics decrease or interrupt alcohol intake abruptly, they will in general experience alcohol withdrawal symptoms. Clinically in most cases it develops a vegetative syndrome with gastroenteropathy, cardiovascular diseases, neurological and psychopathological symptom. Usually alcohol withdrawal symptoms abate after four to seven days, longer courses are rare. Application of drugs is required in approximately one third to one half of the patients. A variety of drugs was suggested for the treatment of alcohol withdrawal. In the first hours of alcohol detoxification, the sensitivity of epinephrine receptors is reduced, but rises afterwards substantially. The number of NMDA-receptors increases during chronic intoxication with ethanol. The standard therapy in Europe (except of Great Britain) is an oral mono therapy with clomethiazole in a dose which depends on the severity of the symptoms. Severe withdrawal symptoms may require treatment on an intensive care unit with infusion therapy, e.g. in the context of a delirium tremens, which represents a life-threatening status. In this case, benzodiazepines have been used successfully as an alternative to clomethiazole.

Results in 95 hemorrhagic stroke patients included in CLASS, a controlled trial of clomethiazole versus placebo in acute stroke patients

BACKGROUND AND PURPOSE

Clomethiazole is a neuroprotective drug that enhances gamma-aminobutyrate type A (GABA(A)) receptor activity. Its efficacy and safety were tested in the CLomethiazole Acute Stroke Study (CLASS). The protocol allowed a CT scan to be done after randomization but within 7 days of stroke onset to minimize delays before start of treatment. Ninety-five of the 1360 patients randomized were diagnosed as having intracranial hemorrhage rather than ischemic stroke. Safety results for clomethiazole compared with placebo in this group are reported.

METHODS

The study included patients with a clinical diagnosis of acute hemispheric cerebral infarction. Treatment was a 24-hour intravenous infusion of 75 mg/kg clomethiazole or placebo. Patients with intracranial hemorrhage discovered on a postrandomization CT were withdrawn from study treatment if treatment was ongoing, and all patients were followed up to 90 days.

RESULTS

Ninety-four patients received treatment, 47 in each group. The hemorrhage was classified as intracerebral in 89 patients (94%). Mortality at 90 days was 19.1% in the clomethiazole group and 23.4% in the placebo group. Sedation was the most common adverse event, occurring at a higher incidence in clomethiazole-treated patients (clomethiazole 53%, placebo 17%), followed by rhinitis and coughing. The incidence and pattern of serious adverse events was similar between the treatment groups. The percentage of patients reaching relative functional independence on the Barthel Index (score >/=60) at 90 days was 59.6% in the clomethiazole group and 53.2% in the placebo group.

CONCLUSIONS

Clomethiazole appears safe to administer to hemorrhagic stroke patients compared with placebo. These results would obviate the need for a CT scan before therapy is initiated in acute stroke. The safety of clomethiazole in hemorrhagic stroke patients will be further evaluated in a prospective study that is under way in North America.

[Alcohol withdrawal syndrome and delirium tremens. Diagnosis and therapy]

The alcohol withdrawal syndrome can be classified into three degrees of severity on the basis of the symptomatology, autonomic withdrawal, predelirium and delirium tremens. In American literature the severity of withdrawal is recorded using the CIWA-A scale (Clinical Institute Withdrawal Assessment--Alcohol). The pathophysiological causes lie in an imbalance between the inhibitory and excitatory neurotransmitters after giving up alcohol. This results in predomination by the excitatory system. Therapeutic intervention is possible here. Clomethiazole has effective sedative actions, stabilises the autonomic nervous system, and is an anticonvulsant. It is the drug of choice for autonomic withdrawal and predelirium. The benzodlazepines have a similar effect, but cannot be controlled so accurately. Carbamazepine can prevent withdrawal convulsions and progression of delirium. Clonidine acts on autonomic withdrawal and, together with neuroleptics and benzodiazepines, is easy to use parenterally for delirium tremens, while parenteral clomethiazole harbours dangers.

Clomethiazole acute stroke study (CLASS): results of a randomized, controlled trial of clomethiazole versus placebo in 1360 acute stroke patients

BACKGROUND AND PURPOSE

The efficacy and safety of the neuroprotective drug clomethiazole was tested in a double blind placebo controlled trial in patients with a clinical diagnosis of acute hemispheric stroke.

METHODS

Patients with symptom onset of </=12 hours before the start of treatment were included in the study. Clomethiazole (75 mg/kg) or placebo was given as an intravenous infusion over a 24-hour period. Patients were followed up for 90 days. The primary efficacy variable was the proportion of patients reaching relative functional independence (>/=60 points on the Barthel Index) at 90 days.

RESULTS

A total of 1360 patients were included. In the main efficacy analysis (n=1353), 56.1% of patients taking clomethiazole and 54.8% of placebo patients reached relative functional independence. The difference was not statistically significant. An analysis of the effect of time since onset of symptoms showed no difference between the treatment groups. Clomethiazole was generally well tolerated and appeared safe in the population studied. Sedation was the most common adverse event, leading to treatment withdrawal that occurred in 15.6% of clomethiazole-treated patients compared with 4.2% of placebo-treated patients. In a subgroup classified before randomization as having total anterior circulation syndrome (TACS) (n=545, or 40% of all randomized patients), the percentage of those reaching relative functional independence was 40.8% on clomethiazole and 29.8% on placebo, a difference of approximately 11 percentage units. TACS patients have clinical symptoms suggesting a "large" stroke.

CONCLUSIONS

Clomethiazole had no adverse or beneficial effect on long-term outcome for all patients but produced sedation. The hypothesis that clomethiazole is effective in patients with large strokes will be tested in a further study.

Hepatotoxic side-effect of clomethiazole

We report on a patient with a history of alcoholism who developed hyperbilirubinemia induced by treatment with clomethiazole during two hospitalizations. After discontinuation of clomethiazole symptoms of cholestasis improved. Clomethiazole is a thiazole analogon and is chemically related to thiamine (vitamin B1). It can be administered as tablets, capsules, mixtures, and a 0.8% solution. Because of its sedative, hypnotic, and anti-convulsive effects it is used in the treatment of alcoholic delirium.

Computed tomography of the brain, hepatotoxic drugs and high alcohol consumption in male alcoholic patients and a random sample from the general male population

Computed tomography (CT) of the brain was performed in a random sample of a total of 195 men and 211 male alcoholic patients admitted for the first time during a period of two years from the same geographically limited area of Greater Stockholm as the sample. The same medical, social and neuroradiological methods were used for examination of the alcoholic inpatients as for the random controls. Laboratory tests were performed, including liver and pancreatic tests. Toxicological screening was performed and the consumption of hepatotoxic drugs was also investigated and the following were the types of drugs used: antiarrhythmics, antiepileptics, antiphlogistics, mixed analgesics, barbiturates, sulphonamides, benzodiazepines, clomethiazole and phenothiazine derivatives, all of which are metabolised by the liver. The group of male alcoholic inpatients and the random sample were then subdivided with respect to alcohol consumption and use of hepatotoxic drugs: Group IA, men from the random sample with low or moderate alcohol consumption and no use of hepatotoxic drugs; IB, men from the random sample with low or moderate alcohol consumption with use of hepatotoxic drugs; IIA, alcoholic inpatients with use of alcohol and no drugs; and IIB, alcoholic inpatients with use of alcohol and drugs. Group IIB was found to have a higher incidence of cortical and subcortical changes than group IA. Group IB had a higher incidence of subcortical changes than group IA, and they differed only in drug use. Groups IIB and IIA only differed in drug use, and IIB had a higher incidence of brain damage except for anterior horn index and wide cerebellar sulci indicating vermian atrophy. Significantly higher serum (S) levels of bilirubin, gamma-glutamyl transpeptidase (GGT), aspartate aminotransferase (ASAT), alanine amino-transferase (ALAT), creatine kinase (CK), lactate dehydrogenase (LD) and amylase were found in IIB. The results indicate that drug use influences the incidence of cortical and subcortical aberrations, except anterior horn index. It is concluded that the groups with alcohol abuse who used hepatotoxic drugs showed a picture of cortical changes (wide transport sulci and clear-cut or high-grade cortical changes) and also of subcortical aberrations, expressed as an increased widening of the third ventricle.

[Treatment of delirium tremens--a comparison between clomethiazole and clorazepate with reference to effectiveness and rate of side effects]

In an open clinical trial patients with full-developed delirium tremens were treated either by controlled infusion of clomethiazol (n = 21) or by intravenous injections of clorazepate (n = 20). Acute symptomatic quickly decreased after a few days and medication could be reduced. By adding haloperidol a further stabilization in patients suffering from vivid hallucinations could be obtained. The duration of intravenous therapy and the total period of treatment did not differ in the two groups. Statistical analysis of cardiovascular parameters revealed a significant lower heart rate under clorazepate therapy. So treatment with clorazepate proved to be an alternative to standard therapy with clomethiazol even for severe cases of delirium tremens regarding its wide therapeutical range and the low rate of cardio-pulmonary complications.

[Alcohol delirium--pathogenesis and therapy]

Alcohol-induced delirium tremens (DT) is a well-known disease with an unpredictable, either favorable or fatal, spontaneous course. The cardinal symptoms are disorientation, hallucinations and autonomic lability. The pathogenesis of DT is still unknown, and the numerous hypothesis have spawned as many therapeutic approaches. Drugs with a cross-tolerance to alcohol have so far proved best. Benzodiazepines and clomethiazole have been considered the drugs of first choice for the past 20 years and more. Improvements in intensive care has helped lower the mortality rate to 3 to 8%. Major tranquilizers with a strong antipsychotic effect and anti-epileptic agents can effectively expand the sedative management of DT. Cerebral convulsions at the beginning of DT appear to dispose the patient to a prolonged course, and preexisting or concomitant disease affecting other organs (complicated DT) clearly prolongs the duration of delirium. The risks and contraindications of clomethiazole are emphasized. The course and outcome of DT is unpredictable--in our patients we found a mortality rate of 3.7% and 12.3% end up in a defective state.

A single-dose study of the pharmacodynamic effects of chlormethiazole, temazepam and placebo in elderly parkinsonian patients

Nine elderly parkinsonian volunteers took single doses of 384 mg of chlormethiazole, 10 mg of temazepam and placebo capsules in a double-blind three-way cross-over study on separate visits at least one week apart. In the 6 hours following the dose, the level of drowsiness, performance on a series of psychomotor tests, effects on parkinsonian symptoms and signs, and standing and lying blood pressure were recorded. Chlormethiazole produced drowsiness on all tests and impaired psychomotor performance, as compared with placebo, without affecting parkinsonian symptoms and signs, or postural blood pressure. Temazepam was consistently less potent than chlormethiazole on tests of drowsiness and psychomotor performance. Both treatments were well tolerated. It is suggested that chlormethiazole is safe to use as a hypnotic at this dosage in this group of patients with Parkinson's disease, while temazepam did not appear to be effective as a hypnotic at this dosage.

Chlormethiazole: current status in the treatment of the acute ethanol withdrawal syndrome

Comparative clinical studies of Chlormethiazole with a vast array of pharmacologically unrelated drugs like benzodiazepines, tiapride, bromocriptine, carbamazepine and phenothiazines over the years clearly established it as a useful, dependable and effective drug to treat patients with moderate to severe ethanol withdrawal syndrome, when used early in a flexible reducing regime tailed off over 7-10 days. It has been found to be highly effective in the treatment, and particularly in the prevention of DT's in high-risk patients, if given at an early stage. This paper critically reviews the important international clinical trial literature of various drugs currently used in the treatment of ethanol withdrawal syndrome, including DT's, it highlights the efficacy and superiority of Chlormethiazole over other drugs, and also discusses the probable mechanism of its actions in these conditions.

Severity of withdrawal in subjects exposed to a combination of alcohol and minor tranquillisers

Fifty patients suffering from the alcohol dependence syndrome were detoxified over a 10-day period using a reducing regime of chlordiazepoxide. Twenty-four had been consuming minor tranquillisers together with alcohol prior to admission. The severity of the withdrawal syndrome was assessed daily but no differences were found between the 26 who had taken alcohol alone and the 24 who had taken a combination of alcohol and drugs. Four from each group had a transient hallucinosis and none had fits.

[Treatment of refractory status convulsivus with chlormethiazole]

A 5 years old girl with status epilepticus refractory to treatment with Diphenylhydantoin at a dose of 30 mg/kg/day and Thiopental in continuous IV perfusion at a dose of 4 mg/kg/h is presented. Control of status was achieved by continuous IV perfusion of Chlormethiazole at a dose of 10 mg/kg/h which also caused respiratory depression. Seizure activity reappeared after IV perfusion of Chlormethiazole was retired, and could be controlled only with Sodium Valproate. Mechanisms of action of Chlormethiazole and its effectiveness in treatment of refractory status epilepticus are revised.

Priapism and psychotropic medication

Priapism is a rare but serious adverse effect of psychotropic drugs resulting from their peripheral alpha-adrenoreceptor blocking action. Two patients developed this during treatment with oral phenothiazines: one was treated surgically with a venous shunt, and the second case resolved after intracavernosal injection of an alpha-adrenoreceptor stimulating drug.

Treatment of delirium tremens in German psychiatric hospitals: results of a recent survey

A questionnaire was sent to all the psychiatric clinics in West Germany to determine their treatment of delirium tremens. Chlormethiazole was found to be the most important drug for treating delirium tremens and was used in more than 90% of clinics. Contraindications for chlormethiazole treatment and side-effects with treatment were also recorded.

A double-blind comparison of chlormethiazole and temazepam in elderly patients with sleep disturbances

The results of this double-blind study showed that both chlormethiazole and temazepam are effective, in the correct dose, for the short-term treatment of sleep disturbance in elderly patients. With chlormethiazole treatment there was no daytime drowsiness, whereas significant daytime drowsiness occurred with temazepam.

Chlormethiazole in intensive care

Patients in the intensive care unit frequently require sedation. The advantages of using an intravenous infusion of chlormethiazole to produce sedation include the rapidity of sedation and recovery, and the lack of cardiovascular effects. Chlormethiazole is contraindicated in patients with hepatic failure or those in whom central nervous system functioning has to be assessed. Provided care is taken, chlormethiazole is a very valuable agent in treating patients in an intensive care unit.

Circulatory and respiratory effects of chlormethiazole

The circulatory and respiratory effects of chlormethiazole were studied in volunteers and patients. The only clinically significant cardiovascular change was an increase in heart rate. However, this is only important if associated with a high arterial pressure in the presence of coronary artery disease. The respiratory effects were not significant.

A double-blind controlled study of chlormethiazole and triazolam as hypnotics in the elderly

This study compared the hypnotic efficacy and the psychometric effects of treatment with either chlormethiazole or triazolam for 9 weeks in elderly patients with sleep disturbance. Chlormethiazole and triazolam were found to be similarly effective in short-term use. However, evidence of sustained hypnotic efficacy throughout the 9 weeks of treatment was obtained for chlormethiazole but not for triazolam. There were daytime withdrawal effects with triazolam, but none with chlormethiazole.

A comparison of chlormethiazole and thioridazine in agitated confusional states of the elderly

Chlormethiazole and thioridazine were found to be equally effective in the management of the agitational component of agitated confusional states in the elderly. Confusion and nocturnal awakening were found to be controlled more effectively with chlormethiazole than with thioridazine. Chlormethiazole treatment also resulted in significant reductions in physical disability as assessed by the Clifton Behaviour Rating Scale. A greater incidence of adverse effects was associated with thioridazine treatment.

Chlormethiazole as a sleep cover for regional anaesthesia

Intravenous chlormethiazole has been used in conjunction with regional anaesthesia to induce sedation in several hundred patients. Advantages of using chlormethiazole include rapid induction and recovery. Disadvantages include nasal irritation.

Experimental studies and clinical experiences on the dependency potential of chlormethiazole

The dependency potential of chlormethiazole has been assessed on the basis of animal studies (rat and monkey) and an extensive analysis of human cases reported in the international clinical literature covering a period of 17 years. The results of the animal studies do not show any major physical or psychological dependence on chlormethiazole. Clinical studies of case reports suggest that the evidence for "primary" dependence on chlormethiazole is weak, as most of the analysable cases had a previous history of alcohol and/or other drug abuse/dependence. Moreover, in a high proportion of these cases there was evidence of simultaneous alcohol and/or other drug abuse. It should be stressed that in this group of patients the dependence on chlormethiazole was invariably reported in connection with long-term out-patient medication, that is, in a way that was not in accordance with recommendations for use of the drug in "dried out" alcoholics and/or drug addicts. Reports of chlormethiazole abuse/dependence from the alcohol/drug addiction indication are may involve a population particularly prone to addiction and, therefore, be unrepresentative for general assessment. Conversely, the findings in animal studies provide indirect support for the favourable clinical experiences with chlormethiazole in the geriatric, psychogeriatric and obstetric indication areas where chlormethiazole has been used extensively for more then a decade in a problem-free manner. The risk which applies to long-term use in alcoholics and/or drug addicts or the emotionally unstable, because of their "dependency proneness", does not seem to apply to the treatment of conditions, such as insomnia and agitation, in the elderly in whom the drug has been found to be very useful by various investigators.(ABSTRACT TRUNCATED AT 250 WORDS)