What is the treatment for a seizure in alcohol withdrawal?

From the Guidelines

The treatment for a seizure in alcohol withdrawal primarily involves benzodiazepines, with intravenous lorazepam (2-4 mg) or diazepam (5-10 mg) administered immediately to stop the seizure, as recommended by the most recent and highest quality study 1. For an active seizure, the goal is to stop the seizure as quickly as possible to prevent further brain damage and other complications.

• Benzodiazepines are the first-line treatment for seizures in alcohol withdrawal, due to their ability to enhance GABA activity in the brain and counteract the neuronal hyperexcitability that occurs when alcohol is withdrawn after chronic use.
• Following the acute management, a benzodiazepine taper is essential to prevent further seizures, typically using longer-acting agents like diazepam (starting at 10-20 mg orally every 6 hours) or chlordiazepoxide (50-100 mg orally every 6 hours), with doses gradually reduced over 3-7 days based on symptoms, as supported by previous studies 1.
• Thiamine (100 mg IV or IM daily for 3-5 days, then 100 mg orally daily) should be given to prevent Wernicke's encephalopathy, a potentially life-threatening complication of alcohol withdrawal.
• Fluid and electrolyte imbalances, particularly hypomagnesemia, hypoglycemia, and hypokalemia, should be corrected to prevent further complications and support the patient's overall health.
• The use of benzodiazepines in alcohol withdrawal is supported by the most recent study 1, which emphasizes the importance of prompt and effective treatment to prevent further seizures and other withdrawal symptoms.

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. Status Epilepticus and Severe Recurrent Convulsive Seizures: In the convulsing patient, the intravenous route is by far preferred. This injection should be administered slowly. However, if intravenous administration is impossible, the intramuscular route may be used. 5 mg to 10 mg initially (I. V. preferred). This injection may be repeated if necessary at 10 to 15 minute intervals up to a maximum dose of 30 mg.

For a seizure in alcohol withdrawal, diazepam (IV) may be used at an initial dose of 5 mg to 10 mg, which can be repeated at 10 to 15 minute intervals up to a maximum dose of 30 mg 2.

• The intravenous route is preferred for administration.
• The injection should be administered slowly.
• Respiratory assistance should be available.
• EEG monitoring of the seizure may be helpful 2.

From the Research

Treatment for Seizure in Alcohol Withdrawal

• The treatment for a seizure in alcohol withdrawal typically involves the use of benzodiazepines, which are considered the first-line treatment for alcohol withdrawal syndrome 3, 4, 5, 6.
• Benzodiazepines, such as diazepam, lorazepam, and chlordiazepoxide, can help to reduce the severity of withdrawal symptoms, including seizures, and prevent the development of more severe complications, such as delirium tremens 3, 5.
• The choice of benzodiazepine may depend on the individual patient's needs and medical history, with diazepam being a commonly recommended option due to its rapid onset of action and long half-life 5.
• In some cases, other medications, such as propofol, may be used in addition to benzodiazepines for patients who are refractory to treatment or who require more intensive care 4.
• Symptom-triggered treatment with benzodiazepines, where medication is administered only as needed in response to withdrawal symptoms, may be a safe and effective approach for managing alcohol withdrawal, including seizures 7.

Key Considerations

• Patients with a history of seizures or delirium tremens may require more intensive treatment and monitoring 3, 4.
• Benzodiazepines should be used with caution in patients with a history of substance abuse or dependence, as well as in elderly patients or those with liver disease 5, 6.
• Other medications, such as phenytoin, may be used in patients with a preexisting seizure disorder, but are not generally recommended for the treatment of alcohol withdrawal seizures 6.