From the Guidelines
The first-line treatment for alcohol withdrawal syndrome is benzodiazepines, with diazepam, lorazepam, and chlordiazepoxide being the most commonly used medications. For most patients, diazepam is preferred at doses of 10-20mg orally every 1-4 hours as needed for symptoms, with frequency adjusted based on withdrawal severity. Lorazepam (1-4mg every 1-4 hours) is preferred for patients with liver disease due to its shorter half-life and lack of active metabolites 1. Treatment typically follows either a fixed-schedule approach (regular doses for 3-5 days with gradual tapering) or symptom-triggered therapy (medication given only when withdrawal symptoms reach a certain threshold on assessment scales like CIWA-Ar). Benzodiazepines are effective because they work on GABA receptors, compensating for the neuronal hyperexcitability caused by alcohol cessation.
Some key points to consider in the management of alcohol withdrawal syndrome include:
- Adequate hydration and thiamine supplementation (100mg IV or IM followed by oral doses) are essential components of management 1.
- Close monitoring of vital signs is necessary, especially in patients with severe withdrawal symptoms or comorbidities 1.
- Severe cases may require ICU admission and intravenous benzodiazepines.
- Early treatment is crucial to prevent progression to severe complications like seizures or delirium tremens.
- The presence of decompensated liver disease should encourage prioritization of a personalized prescription that is symptom-adapted and favors short-acting drugs 1.
- Thiamine should be prescribed as part of the withdrawal process to prevent the onset of Wernicke's encephalopathy, with a level of evidence for prophylactic prescription being low but the benefit-risk balance considered favorable 1.
It's worth noting that while other medications such as carbamazepine, haloperidol, and clonidine may be considered in certain cases, benzodiazepines remain the gold standard for the treatment of alcohol withdrawal syndrome due to their efficacy in reducing withdrawal symptoms and preventing seizures and delirium tremens 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 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 first-line treatment for alcohol withdrawal syndrome is diazepam (PO), with a 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 is indicated for the symptomatic relief of acute agitation, tremor, impending or acute delirium tremens, and hallucinosis in acute alcohol withdrawal 2.
- Key points:
- Diazepam is used for symptomatic relief in acute alcohol withdrawal
- The initial dosage is 10 mg, 3 or 4 times during the first 24 hours
- The dosage is reduced to 5 mg, 3 or 4 times daily as needed
- Diazepam is a benzodiazepine and should be used with caution due to the risk of dependence and withdrawal reactions 2
From the Research
Alcohol Withdrawal Syndrome Treatment
The first-line treatment for alcohol withdrawal syndrome is benzodiazepines, which are effective in preventing seizures and delirium tremens 3, 4, 5, 6.
- Benzodiazepines can be administered on a fixed or symptom-triggered schedule.
- They are recommended for patients with moderate to severe symptoms.
- Other medications such as carbamazepine and gabapentin can be used as adjunctive or alternative therapies for mild to moderate symptoms 4, 5, 6.
Patient Management
Patients with mild to moderate withdrawal symptoms can be treated as outpatients, while those with severe symptoms or at high risk of complications require inpatient treatment 4, 5, 7.
- Outpatient treatment should include supportive care, pharmacotherapy, and daily monitoring for up to five days after the last drink.
- Patients should be assessed for unhealthy alcohol use using tools such as the Alcohol Use Disorders Identification Test-Consumption and the Single Alcohol Screening Question instrument 4.
- Long-term treatment for alcohol use disorder, including pharmacotherapy, should be initiated in addition to withdrawal management 4, 5, 6.
Medication Options
Other medications that can be used in the treatment of alcohol withdrawal syndrome include:
- Carbamazepine: an alternative to benzodiazepines for mild to moderate symptoms 3, 4, 5, 6.
- Gabapentin: a potential adjunctive or alternative therapy for mild to moderate symptoms 4.
- Haloperidol, beta blockers, clonidine, and phenytoin: may be used as adjuncts to a benzodiazepine in the treatment of complications of withdrawal 6.