From the Guidelines
Non-benzodiazepine options for managing alcohol withdrawal syndrome include carbamazepine, which can be administered at 200 mg every 6-8 hours, as an alternative to benzodiazepines, effective in seizure prevention 1.
Non-Benzodiazepine Options
Other non-benzodiazepine options for alcohol withdrawal include:
- Clonidine, at 0.1-0.2 mg every 6-8 hours, to help manage autonomic symptoms
- Gabapentin, useful at 300-600 mg three times daily, particularly for mild to moderate withdrawal
- Valproic acid, which may be used at 500-1000 mg daily in divided doses
- Baclofen, which has shown promise in treating alcohol withdrawal syndrome and preventing relapse, with a recommended dose not exceeding 80 mg/day 1
Mechanism of Action
These medications work through different mechanisms, including:
- Enhancing GABA activity, similar to alcohol
- Modulating calcium channels
- Reducing sympathetic outflow
Essential Components of Withdrawal Management
Regardless of medication choice, vital sign monitoring, hydration, thiamine supplementation (100 mg daily), and electrolyte replacement remain essential components of withdrawal management 1.
Choice of Medication
The choice of non-benzodiazepine medication depends on withdrawal severity, comorbidities, and medication availability. It is essential to consider the potential risks and benefits of each medication and to individualize treatment for each patient.
From the FDA Drug Label
Gabapentin does not exhibit affinity for benzodiazepine, opiate (mu, delta or kappa), or cannabinoid 1 receptor sites. A small number of postmarketing cases report gabapentin misuse and abuse. These individuals were taking higher than recommended doses of gabapentin for unapproved uses Most of the individuals described in these reports had a history of poly-substance abuse or used gabapentin to relieve symptoms of withdrawal from other substances.
Non-benzodiazepine options for managing alcohol withdrawal syndrome may include gabapentin, as it is not a benzodiazepine and does not exhibit affinity for benzodiazepine receptor sites 2.
- Key points:
- Gabapentin is not a scheduled drug
- It has been used to relieve symptoms of withdrawal from other substances, including alcohol
- Careful evaluation and monitoring are recommended when prescribing gabapentin to patients with a history of drug abuse However, the dependence and abuse potential of gabapentin has not been fully evaluated in human studies 2.
From the Research
Non-Benzodiazepine Options for Managing Alcohol Withdrawal Syndrome
- The following non-benzodiazepine GABAergic medications have been studied for the treatment of alcohol withdrawal syndrome:
- These medications have shown promise in reducing the severity of symptoms, preventing more severe withdrawal clinical manifestations, and facilitating entry into a treatment program 3
- Gabapentin has been compared to chlordiazepoxide in a randomized, double-blind study, and was found to result in significantly greater reduction in sedation and a trend to reduced alcohol craving by the end of treatment 7
- Anticonvulsants may offer advantages over benzodiazepines in the outpatient treatment of alcohol withdrawal, including lack of abuse potential, minimal interactions with alcohol, and potential to ameliorate psychiatric symptoms of alcohol withdrawal 4
- The use of non-benzodiazepine anticonvulsants for the treatment of alcohol withdrawal syndrome and alcohol use disorders is supported by growing evidence in the literature 5, 6