From the Guidelines
Alcohol withdrawal syndrome (AWS) should be managed with a symptom-triggered regimen of benzodiazepines, with long-acting benzodiazepines such as diazepam or chlordiazepoxide being the preferred choice for reducing withdrawal symptoms and preventing seizures and delirium tremens. The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale is a useful tool in guiding medication dosing, with a score >8 indicating moderate AWS and a score ≥15 indicating severe AWS 1.
Key Considerations
- Benzodiazepines are considered the 'gold standard' treatment for AWS due to their efficacy in reducing withdrawal symptoms and the risk of seizures and delirium tremens 1.
- Long-acting benzodiazepines provide more protection against seizures and delirium, but short and intermediate-acting benzodiazepines such as lorazepam are safer in elderly patients and those with hepatic dysfunction 1.
- Supportive care includes IV fluids, thiamine 100mg daily for 3-5 days to prevent Wernicke's encephalopathy, folate 1mg daily, and multivitamins 1.
- Patients with severe AWS or those with a history of withdrawal seizures or delirium tremens may require inpatient management with IV diazepam or lorazepam, titrated to symptoms 1.
Treatment Approach
- For mild to moderate withdrawal, a benzodiazepine taper can be used, typically starting with chlordiazepoxide (Librium) 50-100mg every 6 hours on day one, with gradual reduction over 3-5 days.
- Vital signs should be monitored regularly, and the CIWA-Ar scale can guide medication dosing.
- Following acute management, patients should be referred to addiction treatment programs for long-term recovery support.
From the FDA Drug Label
In acute alcohol withdrawal, diazepam may be useful in the symptomatic relief of acute agitation, tremor, impending or acute delirium tremens and hallucinosis Diazepam may be useful in the management of alcohol withdrawal symptoms, including:
- Acute agitation
- Tremor
- Impending or acute delirium tremens
- Hallucinosis 2
From the Research
Alcohol Withdrawal Treatment
- Benzodiazepines are considered the gold standard for treating alcohol withdrawal syndrome, as they ameliorate or prevent symptoms and complications such as autonomic hyperactivity, agitation, combativeness, hallucinations, seizures, delirium, and death 3, 4, 5.
- The most commonly used benzodiazepines for this purpose are lorazepam, chlordiazepoxide, oxazepam, and diazepam, with diazepam being preferred due to its rapid onset of action and long elimination half-life 3.
- Other medications such as beta-blockers, clonidine, and carbamazepine may be used as adjunctive therapy, but are not recommended as monotherapy 5, 6, 7.
- Symptom-triggered approaches and treatment protocols are essential for managing alcohol withdrawal syndrome, especially in critically ill patients 4.
Medication Options
- Diazepam has been shown to be effective in reducing withdrawal severity, delirium, and seizures, and is considered a suitable agent for alcohol withdrawal 3, 5, 6.
- Clonidine may be underutilized in alcohol withdrawal management, and its potential role in improving patient care by addressing elevated blood pressure/pulse and reducing benzodiazepine overuse should be further explored 7.
- Beta-blockers, such as propranolol, have been shown to be equipotent with diazepam in reducing physical withdrawal symptoms and anxiety symptoms, but are ineffective in preventing major motor seizures 6.
Treatment Considerations
- Individualizing therapy with withdrawal scales can result in significantly less medication and shorter treatment 5.
- The choice of benzodiazepine should be guided by duration of action, rapidity of onset, and cost 5.
- Dosage should be individualized based on withdrawal severity, comorbid illness, and history of withdrawal seizures 5.