What is the management of ethanol (etoh) withdrawal?

From the Guidelines

The management of ethanol withdrawal requires a comprehensive approach centered on benzodiazepines as the primary treatment, with a focus on symptom-triggered regimens and adjunctive therapies to prevent complications and improve patient outcomes.

Key Considerations

• For mild to moderate withdrawal, a symptom-triggered regimen using the Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar) is recommended, administering lorazepam 2-4 mg or diazepam 10-20 mg orally every 1-2 hours when CIWA-Ar scores exceed 8-10 1.
• For severe withdrawal or those with a history of withdrawal seizures or delirium tremens, a scheduled regimen is preferred, such as diazepam 10-20 mg orally every 4-6 hours for 24 hours, then tapering over 3-7 days.
• Longer-acting benzodiazepines like diazepam are generally preferred for their smoother withdrawal coverage, though shorter-acting options like lorazepam are better for patients with liver impairment 1.
• Adjunctive treatments include thiamine (100 mg IV/IM for 3-5 days, then 100 mg orally daily), folate (1 mg daily), multivitamins, and correction of electrolyte abnormalities, particularly magnesium and phosphate.

Special Considerations

• Patients with advanced liver disease may require personalized prescription and prioritization of short-acting benzodiazepines to minimize the risk of accumulation and encephalopathy 1.
• Clonidine (0.1-0.2 mg every 6-8 hours) can help manage autonomic symptoms, while antipsychotics like haloperidol may be needed for severe agitation or hallucinations.
• Benzodiazepines work by enhancing GABA activity, which counteracts the CNS hyperexcitability caused by chronic alcohol use and subsequent withdrawal, effectively preventing progression to more severe withdrawal symptoms including seizures and delirium tremens.

Severe or Refractory Cases

• For severe or refractory cases, phenobarbital (loading dose of 10-15 mg/kg followed by 30-120 mg every 4-6 hours) or propofol may be necessary in an ICU setting.
• Regular monitoring is essential to guide dosage adjustment and prevent seizures, and can be stopped after 24 hours if no specific signs appear 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 AND USAGE ... In acute alcohol withdrawal, diazepam tablets may be useful in the symptomatic relief of acute agitation, tremor, impending or acute delirium tremens and hallucinosis

The management of ethanol (etoh) withdrawal involves the use of diazepam 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 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:
  • Initial dosage: 10 mg, 3 or 4 times during the first 24 hours
  • Subsequent dosage: 5 mg, 3 or 4 times daily as needed
  • Use for symptomatic relief of acute alcohol withdrawal symptoms
  • Diazepam is a useful adjunct for relief of symptoms in acute alcohol withdrawal 2 2

From the Research

Ethanol Withdrawal Management

• The management of ethanol withdrawal syndrome involves minimizing symptoms, preventing complications, and facilitating continued abstinence from alcohol 3.
• Benzodiazepines are the standard treatment for ethanol withdrawal syndrome, but they have drawbacks such as cognitive impairment and significant neurologic and medical side effects 4.
• Alternative pharmacologic agents, such as ketamine, have been shown to be effective in managing severe ethanol withdrawal and reducing the need for benzodiazepines 5.
• Symptom-triggered treatment with γ-aminobutyric acid receptor agonists, such as benzodiazepines, is the cornerstone of therapy for ethanol withdrawal syndrome 6.
• Patients with mild or moderate ethanol withdrawal syndrome can be treated as outpatients, while those with severe symptoms or at high risk of complications require inpatient treatment 3.

Treatment Options

• Benzodiazepines, such as diazepam, can be used to prevent alcohol withdrawal seizures 7.
• Ketamine has been shown to be effective in reducing the need for intubation and shortening ICU stay in patients with severe ethanol withdrawal 5.
• Other medications, such as carbamazepine, oxcarbazepine, valproic acid, and gabapentin, have less abuse potential but do not prevent seizures 3.
• Adjunctive therapies, such as antiepileptics, baclofen, dexmedetomidine, ethanol, ketamine, phenobarbital, propofol, and ketamine, may be beneficial in managing benzodiazepine-resistant patients 6.

Patient Care

• Patients with ethanol withdrawal syndrome should be monitored closely and treated promptly to prevent complications 3.
• Goals of care should include immediate management of dehydration, nutritional deficits, and electrolyte derangements; relief of withdrawal symptoms; prevention of progression of symptoms; and treatment of comorbid illnesses 6.
• Patients should be seen daily until symptoms subside, and long-term success depends on facilitating the patient's entry into ongoing treatment 3.