What are the guidelines for inpatient treatment of alcohol withdrawal?

From the Guidelines

Inpatient treatment of alcohol withdrawal should prioritize benzodiazepines as the cornerstone of therapy, with lorazepam (1-4mg) preferred for patients with liver disease due to its shorter half-life and lack of active metabolites, as recommended by the most recent guidelines 1. The management of alcohol withdrawal syndrome (AWS) requires a comprehensive approach, considering the patient's medical and psychiatric history.

Key Considerations

• Benzodiazepines are the primary treatment for AWS, with the goal of reducing the risk of seizures and delirium tremens.
• The choice of benzodiazepine depends on the patient's liver function, with lorazepam preferred in patients with liver disease 1.
• Thiamine (100mg IV/IM for 3-5 days, then oral) should be administered before glucose to prevent Wernicke's encephalopathy, as recommended by recent guidelines 1.
• Fluid and electrolyte imbalances, particularly hypomagnesemia, hypophosphatemia, and hypokalemia, must be corrected.
• Adjunctive medications may include clonidine for autonomic symptoms, haloperidol for hallucinations, and phenobarbital for refractory cases.

Treatment Approach

• Treatment typically begins with frequent assessments using the Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA-Ar), with scores above 8-10 indicating the need for medication.
• The treatment duration typically ranges from 3-7 days, with gradual tapering of benzodiazepines as symptoms resolve.
• The physiological basis for these interventions is to compensate for enhanced glutamate activity and reduced GABA inhibition that occurs when alcohol is removed after chronic use, preventing dangerous autonomic hyperactivity and seizures.

Recent Guidelines

• The 2022 guidelines from the French Association for the Study of the Liver and the French Alcohol Society recommend symptomatic alcohol withdrawal treatment with benzodiazepines until symptoms disappear 1.
• The guidelines also emphasize the importance of personalized prescription, prioritizing short-acting drugs in patients with decompensated liver disease 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION: ... Symptomatic Relief in Acute Alcohol Withdrawal. 10 mg, 3 or 4 times during the first 24 hours, reducing to 5 mg, 3 or 4 times daily as needed 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

The guidelines for inpatient treatment of alcohol withdrawal include:

• Diazepam (PO): 10 mg, 3 or 4 times during the first 24 hours, reducing to 5 mg, 3 or 4 times daily as needed 2
• Chlordiazepoxide (PO): 50 to 100 mg, to be followed by repeated doses as needed until agitation is controlled — up to 300 mg per day 3 Key points:
• Dosage should be individualized for maximum beneficial effect
• The dosage should be increased cautiously to avoid adverse effects
• Patients should be monitored for withdrawal reactions, and the dosage should be adjusted accordingly

From the Research

Guidelines for Inpatient Treatment of Alcohol Withdrawal

• The treatment aims to minimize symptoms, prevent complications, and facilitate continued abstinence from alcohol 4.
• Patients with severe symptoms or who are at high risk of complications should receive inpatient treatment 4, 5.
• Benzodiazepines are the preferred pharmacological agents for treatment of acute alcohol withdrawal and are recommended for inpatient treatment 5, 6.
• Benzodiazepines can be administered on an in-patient basis for the most severe forms of withdrawal 5.
• Protocolized escalation of benzodiazepines as an alternative to a symptom-triggered approach may decrease the need for mechanical ventilation and intensive care unit (ICU) length of stay 7.
• Propofol is appropriate for patients refractory to benzodiazepines 7.
• Phenobarbital may be an alternative for the treatment of alcohol withdrawal, but its efficacy and safety compared to benzodiazepines need further evaluation 8.

Medication Management

• Benzodiazepines should be given at the onset of symptoms and continued until symptoms subside 4.
• Other medications, including carbamazepine, oxcarbazepine, valproic acid, and gabapentin, have less abuse potential but do not prevent seizures 4.
• The choice of benzodiazepine depends on its half-life or route of administration 5.

Patient Care

• Patients with severe alcohol withdrawal should be closely monitored in an intensive care unit (ICU) 7, 8.
• Patients should be seen daily by a physician until symptoms subside 4.
• Treatment should be individualized based on the patient's severity of illness and response to treatment 7, 8.