What medication is used to treat alcohol withdrawal?

From the Guidelines

Benzodiazepines are the primary medications used to treat alcohol withdrawal, with lorazepam being a preferred option for patients with liver disease due to its minimal hepatic metabolism. The treatment of alcohol withdrawal syndrome (AWS) is crucial to prevent potentially life-threatening complications such as seizures or delirium tremens 1. According to the most recent guidelines, benzodiazepines are considered the 'gold standard' treatment for AWS, given their efficacy in reducing both withdrawal symptoms and the risk of seizures and/or delirium tremens 1.

Key Considerations

• For moderate to severe withdrawal, a typical regimen might include diazepam 10-20mg orally every 4-6 hours as needed for symptoms, with dosing tapered over 3-7 days depending on symptom severity.
• Lorazepam 2-4mg every 4-6 hours is often preferred for patients with liver disease since it doesn't require hepatic metabolism.
• Thiamine (vitamin B1) supplementation of 100mg daily is essential to prevent Wernicke's encephalopathy.
• Adequate hydration and electrolyte replacement are also crucial components of treatment.
• Medical supervision is necessary during withdrawal due to the risk of potentially life-threatening complications.

Adjunctive Therapies

• Anticonvulsants like carbamazepine or gabapentin may be used as adjunctive therapy.
• Beta-blockers like propranolol may be used for autonomic symptoms.
• In severe cases, phenobarbital may be considered.

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, with a preference for short-acting drugs in patients with decompensated liver disease 1.

Conclusion Not Applicable

Instead, the focus is on the direct application of the evidence to the clinical scenario, emphasizing the importance of benzodiazepines, particularly lorazepam in patients with liver disease, and the adjunctive use of other medications as needed, always prioritizing the reduction of morbidity, mortality, and improvement of quality of life.

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 INDICATIONS ... In acute alcohol withdrawal, diazepam may be useful in the symptomatic relief of acute agitation, tremor, impending or acute delirium tremens and hallucinosis

The medication used to treat alcohol withdrawal is diazepam (PO), with a typical dosage of 10 mg, 3 or 4 times during the first 24 hours, reducing to 5 mg, 3 or 4 times daily as needed 2. Diazepam may be useful in the symptomatic relief of acute agitation, tremor, impending or acute delirium tremens, and hallucinosis in acute alcohol withdrawal 2.

• Key points:
  • Medication: diazepam (PO)
  • Dosage: 10 mg, 3 or 4 times during the first 24 hours, reducing to 5 mg, 3 or 4 times daily as needed
  • Indication: acute alcohol withdrawal

From the Research

Medications for Alcohol Withdrawal

• Benzodiazepines are the preferred medication for treating alcohol withdrawal, as they decrease the risk of seizures and are safe 3, 4, 5.
• Specific benzodiazepines used for alcohol withdrawal include:
  • Diazepam, which has a favorable pharmacokinetic profile and is recommended for moderate to severe alcohol withdrawal 6, 7.
  • Lorazepam, chlordiazepoxide, and oxazepam, which are also commonly used for this purpose 6.
• Other medications, such as barbiturates, betablockers, clonidine, and neuroleptics, are not recommended as first-line treatments due to limited efficacy or increased risk of adverse effects 3, 4.
• Propofol may be used as an alternative for patients who are refractory to benzodiazepines, but its role is not well established 7.
• Vitamin B1 supplementation is recommended to prevent deficiency and related complications, particularly in patients with poor nutritional status 4.

Treatment Approaches

• Symptom-triggered therapy and protocolized escalation of benzodiazepines are effective approaches for managing alcohol withdrawal 4, 7.
• Individual support and effective communication can reduce the risk of severe withdrawal syndrome 4.
• Planned alcohol withdrawal in specialized hospital units or outpatient settings may be appropriate, depending on the patient's risk factors and severity of withdrawal 4, 7.