From the Guidelines
For ETOH withdrawal tapering, I recommend using a symptom-triggered benzodiazepine approach with lorazepam, starting at a dosage of 6-12 mg/day and tapering off following resolution of the withdrawal symptoms, as this approach has been shown to be effective in preventing seizures and managing withdrawal symptoms 1.
Key Considerations
- The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scale can be helpful for evaluating the severity of AWS, but high scores may be seen in psychiatric conditions that are similar to AWS, such as anxiolytic withdrawal, anxiety disorder, and physical conditions such as sepsis, hepatic encephalopathy, and severe pain 1.
- Long-acting benzodiazepines, such as chlordiazepoxide and diazepam, are recommended for the prevention of seizures, with effects such as anxiety relief, sedation, and somnolence via activation of gamma-aminobutyric acid (GABA) 1.
- Thiamine should be given to all patients with AWS (100-300 mg/day) and maintained for 2-3 months following resolution of their withdrawal symptoms to prevent Wernicke's encephalopathy 1.
Treatment Approach
- Start with lorazepam 6-12 mg/day and taper off following resolution of the withdrawal symptoms, as recommended in the guidelines 1.
- For severe withdrawal or history of seizures/delirium tremens, consider a fixed-schedule regimen such as diazepam 10mg every 6 hours for 24 hours, then 10mg every 8 hours for 24 hours, followed by 10mg every 12 hours for 24 hours, then discontinue.
- Ensure adequate hydration and electrolyte replacement, particularly magnesium and potassium.
Adjunctive Medications
- Clonidine may be used for autonomic symptoms (0.1-0.2mg every 6-8 hours) 1.
- Thiamine 100mg daily should be given to prevent Wernicke's encephalopathy 1.
From the Research
ETOH Withdrawal Taper
- The use of benzodiazepines, such as diazepam, lorazepam, and chlordiazepoxide, is a common approach for managing alcohol withdrawal symptoms 2, 3, 4.
- Diazepam has been suggested as a preferred benzodiazepine for treating moderate to severe alcohol withdrawal due to its rapid onset of action and long elimination half-life, which allows for a smoother withdrawal process 2.
- A loading dose of diazepam can simplify alcohol withdrawal therapy, taking advantage of the drug's kinetic tapering and effectiveness of nonpharmacologic maneuvers 5.
- The selection of a benzodiazepine for alcohol withdrawal should be based on factors such as availability of dosage forms, additive effect with alcohol, anticonvulsant effect, and duration of effect in the body 4.
- Studies have compared the effectiveness of different benzodiazepines, such as lorazepam and chlordiazepoxide, in preventing delirium tremens and managing alcohol withdrawal symptoms, with no significant differences found in some studies 6.
- The use of a symptom-based approach and careful titration of benzodiazepines can help minimize the risk of over-sedation and other adverse effects 2, 3.