What are non-benzodiazepine (non-BZD) anti-anxiolytic medications for immediate relief of alcohol withdrawal symptoms?

From the Guidelines

For immediate non-benzodiazepine treatment of alcohol-related anxiety, buspirone is a primary recommendation at 5-10mg three times daily, typically for at least 2-4 weeks to achieve full effect. This recommendation is based on the most recent and highest quality study available, which suggests that buspirone is a useful alternative to benzodiazepines for the treatment of anxiety in patients with alcohol use disorder 1. Other options for immediate relief include hydroxyzine at 25-50mg every 6 hours as needed, beta-blockers like propranolol (10-40mg as needed) to help with physical symptoms of anxiety, and gabapentin at 300-600mg three times daily, which may also help with alcohol withdrawal symptoms.

Non-BZD Anti-Anxiolytic Medications

Some key points to consider when using these medications include:

• Buspirone affects serotonin 5-HT1A receptors and may take 2-4 weeks to become effective 1
• Hydroxyzine blocks histamine receptors and can be used for more immediate relief
• Beta-blockers prevent adrenaline effects and can help with physical symptoms of anxiety
• Gabapentin modulates GABA and calcium channels and may also help with alcohol withdrawal symptoms
• SSRIs like sertraline (50-200mg daily) are useful for longer-term management but take weeks to become effective

Important Considerations

It's essential to combine medication with counseling or therapy for alcohol use disorder and to monitor for side effects, particularly when these medications are used during alcohol withdrawal. The use of benzodiazepines and other medications with potential for abuse should be avoided beyond the initial 10-14 days of treatment, as they carry a risk of dependence and withdrawal symptoms 1.

Additional Options

Other compounds, such as topiramate and baclofen, have been tested in the treatment of alcohol withdrawal syndrome and may be considered as alternative options 1. However, the evidence for these medications is not as strong as for buspirone and other non-benzodiazepine anti-anxiolytics.

From the Research

Non-BZD Anti-Anxiolytic Medications for Alcohol Withdrawal Symptoms

• The following non-benzodiazepine (non-BZD) medications have been investigated for the treatment of alcohol withdrawal symptoms:
  • Carbamazepine 2
  • Valproate 2, 3
  • Sodium oxybate 2
  • Baclofen 2, 4, 3
  • Gabapentin 2, 4, 3
  • Topiramate 2
  • Clomethiazole 3
  • Gamma hydroxybutyrate (GHB) 3
  • Pregabalin 3
  • Neurosteroids 3
  • Tiagabine 3
  • Vigabatrin 3
• These medications may be used as alternatives or adjuncts to benzodiazepines for the treatment of alcohol withdrawal symptoms, but their efficacy and safety may vary.
• Benzodiazepines are still considered the gold standard for the treatment of alcohol withdrawal syndrome due to their well-established efficacy and safety profile 5, 2, 6.

Immediate Relief of Alcohol Withdrawal Symptoms

• For immediate relief of alcohol withdrawal symptoms, benzodiazepines such as diazepam, lorazepam, and midazolam are commonly used due to their rapid onset of action 5, 2.
• Non-benzodiazepine medications may not provide immediate relief and may be used in conjunction with benzodiazepines or as part of a longer-term treatment plan.