Lorazepam Dosing for Alcohol Withdrawal Management at Home
For outpatient management of alcohol withdrawal, lorazepam should be administered at 2-4 mg every 6-8 hours initially, with gradual tapering over 5-7 days based on symptom severity. 1
Appropriate Patient Selection for Home Management
Home management is only appropriate for patients with:
- Mild to moderate withdrawal symptoms (CIWA-Ar score <15)
- No history of seizures or delirium tremens
- Adequate social support
- No significant comorbidities 1
Dosing Protocol
Initial Dosing
- Start with 2-4 mg orally every 6-8 hours based on symptom severity 1, 2
- For elderly or debilitated patients: Start with 1-2 mg/day in divided doses 2
Symptom-Triggered Approach (Preferred)
- Use CIWA-Ar scale to assess withdrawal severity:
- CIWA-Ar ≤7 (mild): Monitor, may not require medication
- CIWA-Ar 8-14 (moderate): Give 2 mg lorazepam
- CIWA-Ar ≥15 (severe): Not appropriate for home management, requires hospitalization 1
- Reassess symptoms every 1-2 hours initially, then every 4-8 hours as symptoms improve
- This approach has been shown to reduce total benzodiazepine use by up to 80% compared to fixed-schedule dosing 3
Tapering Schedule
- Days 1-2: Full dose (typically 6-8 mg/day in divided doses)
- Days 3-4: Reduce by 20-25% (to approximately 4-6 mg/day)
- Days 5-6: Reduce by another 20-25% (to approximately 3-4 mg/day)
- Day 7: Final reduction to 1-2 mg/day before discontinuation 1, 2
Monitoring Requirements
- Daily follow-up (in person or telehealth) until symptoms subside 1
- Monitor for:
- Progression of withdrawal symptoms
- Medication adherence
- Signs of complications (seizures, hallucinations)
- Need for dose adjustments 1
Important Considerations
Safety Precautions
- Dispense lorazepam in small quantities to reduce misuse risk 1
- Mix lorazepam oral concentrate with liquid or semi-solid food and consume immediately 2
- Ensure patient has a reliable caregiver present during withdrawal period
- Provide clear instructions on when to seek emergency care (worsening symptoms, seizures, hallucinations)
Nutritional Support
- Thiamine supplementation: 100-300 mg daily for 2-3 months 1
- B-complex vitamins including folate, B12, and B6 1
- Zinc and vitamin D supplementation as needed 1
Contraindications for Home Management
- CIWA-Ar score ≥15
- History of withdrawal seizures or delirium tremens
- Significant comorbidities
- Inadequate social support
- Previous failed outpatient withdrawal attempts 1
Follow-Up Care
- Arrange for addiction treatment follow-up after successful withdrawal
- Consider medications to reduce relapse (acamprosate, naltrexone) 1
- Recommend mutual help groups such as Alcoholics Anonymous 1
Clinical Pearls
- Lorazepam is preferred over diazepam in patients with liver dysfunction due to its shorter half-life and simpler metabolism 1, 4
- Symptom-triggered dosing results in less total benzodiazepine use and shorter treatment duration compared to fixed-schedule dosing 3
- Antipsychotics should not be used as standalone medications for alcohol withdrawal as they increase seizure risk 1
- Return visit rates after ED discharge for alcohol withdrawal approach 25%, highlighting the importance of close follow-up 5
- Gradual tapering is essential to avoid withdrawal reactions from the benzodiazepine itself 1, 2