Diazepam Dosing for Alcohol Withdrawal
For alcohol withdrawal syndrome, diazepam should be administered at 10 mg orally 3-4 times during the first 24 hours, then reduced to 5 mg 3-4 times daily as needed. 1
Initial Assessment and Dosing Strategy
Symptom-triggered approach is preferred over fixed-schedule dosing:
- Reduces total medication required (37.5 mg vs 231.4 mg in fixed-schedule)
- Shortens treatment duration (20 hours vs 62.7 hours)
- Equally effective at preventing complications 2
Loading dose strategy is effective for moderate to severe withdrawal:
- Initial dose: 20 mg oral diazepam
- Repeat every 1-2 hours until symptoms resolve
- Most patients require a median of 3 doses (60 mg total) 3
- Monitor using a standardized assessment tool (e.g., CIWA-Ar score)
Dosing Based on Withdrawal Severity
Mild-Moderate Withdrawal (CIWA-Ar score 8-14):
- 5-10 mg orally every 4-6 hours as needed
- Reassess before each dose
Severe Withdrawal (CIWA-Ar score ≥15):
- 10-20 mg orally every 1-2 hours until symptoms improve
- Then taper to 5-10 mg every 4-6 hours as needed
High Seizure Risk:
- Loading dose approach: 20 mg orally every hour to minimum total of 60 mg
- This approach has shown effectiveness in preventing withdrawal seizures 4
Special Considerations for Liver Disease
- Diazepam can be used in patients with hepatic insufficiency if properly monitored:
- Advantage: Rapid onset allows accurate titration to effect
- Unlike chlordiazepoxide, diazepam's metabolite (desmethyldiazepam) is not more sedating than the parent drug 5
- Ensure dosing interval exceeds time-to-peak effect (approximately 2 hours for oral administration)
- Assess for sedation before each dose
Tapering and Discontinuation
- After stabilization, gradually taper diazepam to prevent withdrawal reactions
- Typical taper schedule:
- Reduce dose by 5 mg every 1-2 days
- If withdrawal symptoms recur, return to previous dose and slow the taper
- Total treatment duration typically 7-10 days
Monitoring Parameters
- Vital signs (blood pressure, heart rate, temperature)
- CIWA-Ar score before each dose
- Level of sedation and respiratory status
- Signs of benzodiazepine toxicity (excessive sedation, respiratory depression)
- Emergence of delirium tremens or seizures
Important Cautions
- Avoid rapid IV administration which may precipitate seizures 6
- Be prepared to support ventilation if combining with other sedative agents
- Benzodiazepines are considered the gold standard for AWS treatment 6
- Flumazenil may be used to reverse life-threatening respiratory depression but can precipitate seizures 6
- Avoid long-term use beyond 10-14 days due to risk of dependence 6
This symptom-triggered approach with diazepam has been demonstrated to be safe, comfortable, and associated with decreased medication quantity and treatment duration while effectively preventing withdrawal complications.