What is the treatment for alcoholic withdrawal?

Treatment of Alcohol Withdrawal

The standard treatment for alcohol withdrawal syndrome is benzodiazepines, particularly diazepam at a dose of 10 mg 3-4 times during the first 24 hours, reducing to 5 mg 3-4 times daily as needed, combined with supportive care and nutritional supplementation. 1, 2

Assessment and Severity Classification

Severity of alcohol withdrawal should be evaluated using validated tools:

• CIWA-Ar score:
  • ≤7: Mild (monitor, may not require medication)
  • 8-14: Moderate (initiate benzodiazepine treatment)
  • ≥15: Severe (aggressive benzodiazepine treatment, consider inpatient management) 1

Pharmacological Management

First-Line Treatment: Benzodiazepines

• Diazepam is preferred due to:

  • Shortest time to peak effect (facilitates rapid symptom control)
  • Longest elimination half-life (provides smoother withdrawal with self-tapering effect)
  • Decreased risk of breakthrough symptoms and seizures 3

• Dosing protocol:

  • Initial: 10 mg 3-4 times during first 24 hours
  • Maintenance: Reduce to 5 mg 3-4 times daily as needed 2
  • Loading dose technique: Give diazepam every 1-2 hours initially until clinical improvement or mild sedation 4

• Alternative benzodiazepines when diazepam is contraindicated:

  • Lorazepam: Preferred in elderly patients or those with severe liver disease
  • Chlordiazepoxide: Another commonly used option 1, 3

Second-Line/Adjunctive Medications

• Carbamazepine or gabapentin: Effective for mild withdrawal symptoms or as adjuncts to benzodiazepines 5

• Baclofen: GABA-B receptor agonist that reduces alcohol cravings; particularly useful in patients with liver disease 1

• Avoid:

  • Phenothiazines, barbiturates, paraldehyde (due to toxicity)
  • Beta-blockers (increase risk of hallucinations)
  • Clonidine (increases risk of nightmares) 6, 4

Nutritional Support

• Thiamine supplementation: 100-300 mg/day for 4-12 weeks to prevent Wernicke's encephalopathy 1

  • Administer 100 mg thiamine before giving dextrose-containing solutions 7

• Nutritional requirements:

  • Protein: 1.2-1.5 g/kg/day
  • Calories: 35-40 kcal/kg/day 1

• Additional supplements: Vitamin B12, folic acid, pyridoxine, vitamin D, and zinc 1

Management of Complications

Seizures

• Treat with benzodiazepines (oral route preferred)
• Phenytoin should only be used in patients with pre-existing seizure disorders 4

Hallucinations

• Benzodiazepines are first-line
• Haloperidol may be added for persistent hallucinations while continuing benzodiazepines 4

Delirium Tremens

• Aggressive benzodiazepine therapy
• Continuous monitoring of vital signs
• Fluid-electrolyte support
• Respiratory support if necessary 6

Treatment Setting

• Outpatient management is appropriate for:

  • Mild to moderate withdrawal symptoms
  • No history of severe withdrawal (seizures or delirium tremens)
  • No significant comorbidities
  • Reliable support system 5

• Inpatient management is indicated for:

  • Severe withdrawal symptoms (CIWA-Ar ≥15)
  • History of seizures or delirium tremens
  • Significant medical or psychiatric comorbidities
  • Lack of reliable support system 1, 5

Long-Term Management for Alcohol Use Disorder

After acute withdrawal management, consider:

• Pharmacotherapy options:

  • Naltrexone: 50 mg once daily for 3-12 months (avoid in patients with liver disease) 8, 1
  • Acamprosate: 666 mg three times daily for 3-6 months (initiated 3-7 days after last alcohol consumption) 8, 1
  • Baclofen: Particularly useful in patients with liver disease 1

• Psychosocial interventions:

  • Cognitive-Behavioral Therapy
  • Motivational Interviewing
  • Support groups (e.g., Alcoholics Anonymous)
  • Individual psychotherapy 8, 1

Monitoring and Follow-up

• Monitor outpatients daily for up to five days after their last drink
• Assess for symptom improvement and need for additional treatment
• Gradually taper benzodiazepines to prevent withdrawal reactions 2, 5

Common Pitfalls to Avoid

• Underdosing benzodiazepines: Can lead to progression of withdrawal symptoms
• Administering thiamine after dextrose: Can precipitate Wernicke's encephalopathy
• Relying solely on pharmacotherapy: Psychosocial interventions are essential components
• Failing to address long-term treatment: Acute withdrawal management is only the first step toward rehabilitation 1, 7, 4