From the Guidelines
For alcohol withdrawal with a CIWA score of 18, diazepam is the recommended first-line treatment, as it provides a smoother withdrawal process and reduces the risk of breakthrough symptoms, according to the most recent and highest quality study 1.
Comparison of Diazepam, Lorazepam, and Phenobarbital
- Diazepam is preferred due to its long half-life and active metabolites, which directly counteract the hyperexcitatory state induced by alcohol withdrawal.
- Lorazepam may be safer in patients with severe liver disease due to its simpler metabolism.
- Phenobarbital is generally reserved for cases resistant to benzodiazepines or in patients with contraindications to their use.
Treatment Protocol
- Start with 10-20 mg of oral diazepam every 1-2 hours until symptoms are controlled (CIWA score < 10).
- Once stabilized, transition to a symptom-triggered regimen, administering 5-10 mg of diazepam when CIWA score is > 10.
- Continue this approach for 3-5 days, tapering the frequency as withdrawal symptoms improve.
- If the patient has significant liver disease, switch to lorazepam (Ativan) at 2-4 mg orally every 1-2 hours, following a similar protocol.
Additional Considerations
- Ensure proper hydration, electrolyte balance, and thiamine supplementation (100 mg IV or IM daily for 3-5 days) to prevent Wernicke encephalopathy and support overall health.
- Monitor vital signs and CIWA scores regularly to assess the effectiveness of treatment and adjust the protocol as needed.
- Be prepared to escalate care if symptoms worsen or complications arise, such as delirium tremens or seizures.
From the Research
Comparison of Diazepam, Ativan (Lorazepam), and Phenobarbital
- Diazepam is considered a preferred benzodiazepine for the treatment of patients experiencing moderate to severe alcohol withdrawal due to its rapid control of symptoms and self-tapering effect 2.
- Lorazepam is also commonly used for the treatment of alcohol withdrawal, especially in patients with liver disease, as it is considered safer than diazepam in these cases 3.
- Phenobarbital is not typically used as a first-line treatment for alcohol withdrawal, and its use is not supported by the provided evidence.
- The Clinical Institute Withdrawal Assessment (CIWA) score is used to assess the severity of alcohol withdrawal symptoms, with a score of 18 indicating moderate to severe withdrawal symptoms.
- Benzodiazepines, such as diazepam and lorazepam, are the primary treatment for moderate to severe alcohol withdrawal symptoms, with the goal of preventing progression to more severe symptoms and complications 2, 4, 5.
Pharmacokinetics and Efficacy
- Diazepam has a rapid onset of action and a long elimination half-life, which allows for self-tapering and reduces the risk of rebound phenomena 2.
- Lorazepam is also effective in treating alcohol withdrawal symptoms, but its pharmacokinetics are different from those of diazepam, with a shorter elimination half-life 3.
- The loading dose technique, using diazepam or other benzodiazepines, can simplify pharmacotherapy and prevent complications in patients with alcohol withdrawal 4, 5.
Clinical Guidelines
- Patients with moderate to severe alcohol withdrawal symptoms, as indicated by a CIWA score of 18, should be treated with benzodiazepines, such as diazepam or lorazepam, as first-line therapy 2, 3, 5.
- The treatment of alcohol withdrawal should be individualized, taking into account the patient's medical history, liver function, and other factors 3, 6.