What is the management of Alcohol Withdrawal Syndrome (AWS)?

From the Guidelines

Management of alcohol withdrawal requires a systematic approach using benzodiazepines as the primary treatment, with lorazepam 1-2 mg orally every 4-6 hours as needed, or diazepam 10 mg orally every 6-8 hours, tapering over 3-5 days, as the preferred initial treatment. This approach is based on the most recent and highest quality study available, which emphasizes the importance of benzodiazepines in reducing withdrawal symptoms and preventing seizures and delirium tremens 1.

Key Considerations

• For severe withdrawal or patients at risk for seizures or delirium tremens, initiate a symptom-triggered protocol using the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale, administering lorazepam 2-4 mg IV every 1-2 hours based on CIWA scores >10, reassessing frequently 1.
• Thiamine supplementation is essential, with 100 mg IV or IM for 3-5 days, then 100 mg orally daily, to prevent Wernicke's encephalopathy 1.
• Maintain hydration with IV fluids if needed and correct electrolyte imbalances, particularly magnesium and potassium.
• For patients with a history of withdrawal seizures, consider adding carbamazepine 200 mg orally four times daily or valproic acid 500 mg orally twice daily, although the primary treatment remains benzodiazepines 1.

Rationale

Benzodiazepines are considered the 'gold standard' treatment for alcohol withdrawal syndrome due to their efficacy in reducing withdrawal symptoms and the risk of seizures and delirium tremens 1. The choice between long-acting and short-acting benzodiazepines depends on the patient's condition, with long-acting benzodiazepines like diazepam providing more protection against seizures and delirium, but short-acting benzodiazepines like lorazepam being safer in elderly patients and those with hepatic dysfunction 1.

Additional Considerations

• Other medications like clonidine, atenolol, carbamazepine, valproic acid, gamma-hydroxybutyrate, topiramate, baclofen, gabapentin, and pregabalin have been studied for the treatment of alcohol withdrawal, but their use is not widely recommended due to insufficient evidence or potential for abuse 1.
• The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale is useful in evaluating the severity of alcohol withdrawal syndrome and guiding treatment, but high scores may also be seen in other conditions, and thus it should not be used for diagnosis alone 1.

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 For the relief of withdrawal symptoms of acute alcoholism, the parenteral form* is usually used initially. If the drug is administered orally, the suggested initial dose is 50 to 100 mg, to be followed by repeated doses as needed until agitation is controlled — up to 300 mg per day

Management of Alcohol Withdrawal can be done using:

• Diazepam: useful in the symptomatic relief of acute agitation, tremor, impending or acute delirium tremens and hallucinosis 2
• Chlordiazepoxide: initial dose of 50 to 100 mg orally, followed by repeated doses as needed until agitation is controlled — up to 300 mg per day 3

From the Research

Management of Alcohol Withdrawal

• The management of alcohol withdrawal typically involves the use of benzodiazepines, which are considered the gold standard for treatment 4.
• Benzodiazepines such as diazepam, chlordiazepoxide, oxazepam, and lorazepam are commonly used to ameliorate or prevent the symptoms and complications of moderate to severe alcohol withdrawal 5.
• The selection of a benzodiazepine for alcohol withdrawal is guided by several factors, including availability of other than oral dosage forms, differences in additive effect with alcohol, differences in anticonvulsant effect, and differences in duration of effect in the body 6.
• Diazepam is often preferred due to its rapid onset of action and long elimination half-life, which allows for a smoother withdrawal with a lower incidence and severity of breakthrough symptoms and rebound phenomena 5.
• Supportive care, including the administration of thiamine hydrochloride and fluid and electrolyte replacement, is also an essential part of the management of alcohol withdrawal 7.
• Other medications, such as anticonvulsants, barbiturates, and adrenergic drugs, may also be used in certain cases, but benzodiazepines remain the first-line treatment 8, 4.
• A symptom-triggered regimen is often favored over a fixed tapering dose regimen, although monitoring through scales can be cumbersome 4.