What non-stimulant medications are used for alcohol withdrawal management?

From the Guidelines

Non-stimulant medications such as benzodiazepines, anticonvulsants, and adrenergic antagonists are commonly used for alcohol withdrawal management, with benzodiazepines being the first-line treatment, as supported by the most recent evidence 1.

Medication Options

• Benzodiazepines: diazepam (5-10mg every 6 hours), chlordiazepoxide (25-100mg every 6 hours), or lorazepam (1-4mg every 6 hours) for 3-7 days with tapering doses, with lorazepam preferred for patients with liver disease.
• Anticonvulsants: carbamazepine (200mg 3-4 times daily), valproic acid (500-1000mg daily), or gabapentin (300-600mg three times daily) as alternatives or adjuncts, especially for mild to moderate withdrawal.
• Beta-blockers: propranolol (10-20mg every 6 hours) to manage autonomic symptoms like tachycardia and hypertension.
• Clonidine: an alpha-2 agonist, at 0.1-0.2mg every 6 hours to reduce autonomic hyperactivity.

Additional Considerations

• Thiamine supplementation (100mg daily) is essential to prevent Wernicke's encephalopathy.
• Acamprosate and naltrexone may be considered for maintaining abstinence in patients with alcohol dependence, as suggested by earlier studies 1.
• Baclofen, a GABA-B receptor agonist, has shown promise in promoting alcohol abstinence in patients with alcohol-related liver disease, but more research is needed to confirm its efficacy 1.

Key Takeaways

• Benzodiazepines are the primary treatment for alcohol withdrawal, with anticonvulsants and adrenergic antagonists used as alternatives or adjuncts.
• Thiamine supplementation is crucial to prevent Wernicke's encephalopathy.
• Acamprosate, naltrexone, and baclofen may be considered for maintaining abstinence in patients with alcohol dependence, but their use should be guided by the most recent evidence and individual patient needs.

From the FDA Drug Label

THE POTENTIATING ACTION OF HYDROXYZINE MUST BE CONSIDERED WHEN THE DRUG IS USED IN CONJUNCTION WITH CENTRAL NERVOUS SYSTEM DEPRESSANTS SUCH AS NARCOTICS, NON-NARCOTIC ANALGESICS AND BARBITURATES. Patients should also be advised against the simultaneous use of other CNS depressant drugs, and cautioned that the effects of alcohol may be increased

The medication hydroxyzine can be used for alcohol withdrawal management as it can potentiate the effects of central nervous system depressants, and patients are cautioned about the increased effects of alcohol.

• Key points:
  • Hydroxyzine can be used with caution in patients with risk factors for QT prolongation.
  • Dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range.
  • Sedating drugs may cause confusion and over sedation in the elderly. 2

From the Research

Non-Stimulant Medications for Alcohol Withdrawal

• The following non-stimulant medications are used for alcohol withdrawal management:
  • Anticonvulsants, such as carbamazepine and divalproex, which have been shown to be as effective as benzodiazepines in treating alcohol withdrawal symptoms 3
  • Gabapentin and vigabatrin, newer anticonvulsants that appear to reduce alcohol withdrawal symptoms in preclinical and open-label clinical trials 3
  • Carbamazepine, which has been found to possess a useful pharmacotherapeutic potential in the management of acute alcohol withdrawal syndrome 4
• These medications may offer advantages over benzodiazepines, including lack of abuse potential, minimal interactions with alcohol, and potential to ameliorate psychiatric symptoms of alcohol withdrawal 3
• The choice of medication depends on the severity of withdrawal symptoms and the presence of other medical conditions, such as hepatic or hematologic complications 3, 5

Specific Medications and Their Uses

• Carbamazepine: can be used to treat mild to moderate withdrawal symptoms, and may be effective in reducing post-withdrawal alcohol use 3, 6
• Gabapentin: can be used to treat mild symptoms, and may be used as an adjunctive or alternative therapy to benzodiazepines for moderate to severe symptoms 6
• Divalproex: may reduce symptoms of alcohol withdrawal, but its use is limited in patients with severe hepatic or hematologic complications 3

Clinical Management

• Patients with mild to moderate withdrawal symptoms can be treated as outpatients with supportive care and pharmacotherapy, including non-stimulant medications like carbamazepine and gabapentin 6
• Physicians should monitor outpatients with alcohol withdrawal syndrome daily for up to five days after their last drink to verify symptom improvement and evaluate the need for additional treatment 6