Successful Treatment of Refractory Delirium Tremens with Enteral Alcohol: A Novel Solution to an Ever Clearer Problem
Jagjot Singh1, Ramanjot Kaur1, Harneel Saini2, Jonas Salna2
1Government Medical College, Amritsar, 2St. Lukes
Objective:
To describe a rare case of benzodiazepine- and barbiturate-refractory delirium tremens successfully treated with enteral ethanol, and to highlight its potential role as a rescue therapy when conventional approaches fail.
Background:
Delirium tremens (DT) represents the most severe form of alcohol withdrawal, characterized by delirium, autonomic instability, and a mortality rate approaching 15% without treatment. Although benzodiazepines and barbiturates remain the mainstay of therapy, a small subset of patients exhibit refractory withdrawal despite maximal dosing. Ethanol, historically used for alcohol withdrawal management, has largely fallen out of favor due to dosing challenges and safety concerns. However, recent reports suggest that carefully monitored enteral ethanol may offer therapeutic benefit in selected refractory cases.
Design/Methods:
We present a 49-year-old man with severe alcohol use disorder admitted after collapse and seizure following abrupt alcohol cessation. Despite escalating doses of benzodiazepines, phenobarbital (31 mg/kg), propofol, and dexmedetomidine, he remained severely agitated with life-threatening autonomic instability. After multidisciplinary discussion and informed consent, enteral ethanol was initiated via nasogastric tube, titrated to approximate his baseline daily intake (~34 mL of pure ethanol per dose).
Results:
Within 12–24 hours of ethanol administration, the patient demonstrated marked resolution of tremors, hallucinations, and autonomic hyperactivity. Sedatives were discontinued, and his clinical status stabilized without complications such as oversedation, aspiration, or electrolyte derangements. He was discharged neurologically intact on hospital day 11 and remained abstinent at one-month follow-up.
Conclusions:
This case demonstrates that enteral ethanol, under intensive monitoring, can serve as an effective last-resort therapy for refractory DT. While not recommended for routine use, its success in this case underscores the importance of multidisciplinary flexibility and re-examination of historical treatments in modern neurocritical care.
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