What is the treatment (Tx) for alcohol withdrawal?

Treatment of Alcohol Withdrawal Syndrome

Benzodiazepines are the gold standard treatment for alcohol withdrawal syndrome (AWS), with long-acting benzodiazepines like diazepam being preferred for most patients due to their rapid onset and self-tapering properties. 1

Initial Assessment and Treatment Setting

Severity Assessment

• Use Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale to assess severity:
  • Score >8: Moderate AWS
  • Score ≥15: Severe AWS 1

Treatment Setting Decision

• Outpatient management is appropriate for:

  • Mild to moderate withdrawal without complications
  • No history of seizures or delirium tremens
  • Adequate social support 1, 2

• Inpatient management is required for:

  • Severe AWS with complications (delirium, seizures)
  • History of withdrawal seizures or delirium tremens
  • Significant comorbidities (psychiatric or physical)
  • Inadequate social support
  • Failed outpatient treatment 1

Pharmacological Treatment

First-Line Therapy: Benzodiazepines

For Most Patients:

• Diazepam (preferred): 10 mg PO 3-4 times during first 24 hours, then reducing to 5 mg 3-4 times daily as needed 3
  • Advantages: Rapid onset, long half-life providing smoother withdrawal 4
  • Dosing: Symptom-triggered approach preferred over fixed schedule 5

For Special Populations:

• Lorazepam: 1-4 mg PO/IV/IM every 4-8 hours 1
  • Preferred for patients with:
    • Severe AWS
    • Advanced age
    • Recent head trauma
    • Liver failure
    • Respiratory failure
    • Obesity 1
  • Starting dose: 6-12 mg/day, tapered following symptom resolution 1

Adjunctive Therapies:

• Thiamine: 100-300 mg/day for all AWS patients

  • Continue for 2-3 months after withdrawal resolution
  • Must be given before administering IV glucose to prevent Wernicke encephalopathy 1
  • Higher doses (100-500 mg/day) for patients with suspected Wernicke encephalopathy 1

• Carbamazepine: 200 mg PO every 6-8 hours

  • Alternative to benzodiazepines for seizure prevention 1
  • Can be used for mild symptoms 2

• Gabapentin: Alternative for mild symptoms or as adjunct therapy 2

• Haloperidol: 0.5-5 mg PO/IM every 8-12 hours

  • Only as adjunctive therapy for agitation or psychotic symptoms not controlled by benzodiazepines
  • Not recommended as standalone treatment (increases seizure risk) 1, 6

Supportive Care:

• Fluid and electrolyte replacement (especially magnesium)
• Comfortable environment
• Close monitoring of vital signs 1

Treatment Duration and Monitoring

• Monitor patients daily for up to 5 days after last drink 2
• Taper benzodiazepines gradually to prevent withdrawal reactions 3
• Limit benzodiazepine treatment to 7-14 days to prevent dependence 1, 6

Common Pitfalls to Avoid

1. Using CIWA protocol for diagnosis: The CIWA is for severity assessment and treatment planning, not for diagnosis of AWS 1

2. Using antipsychotics as primary treatment: These increase seizure risk and should only be used as adjuncts to benzodiazepines 1, 6

3. Failing to provide thiamine: Must be given before glucose administration to prevent precipitating acute thiamine deficiency 1

4. Inadequate benzodiazepine dosing: Undertreating can lead to progression to seizures and delirium tremens 7

5. Prolonged benzodiazepine use: Should be limited to 7-14 days to prevent dependence 1

Long-Term Management

After acute withdrawal management, consider:

• Psychiatric consultation for evaluation and long-term abstinence planning 1
• Medications to maintain abstinence (acamprosate, naltrexone, disulfiram) 1
• Psychosocial support and referral to mutual help groups like Alcoholics Anonymous 1