What is the recommended treatment for alcohol withdrawal?

Treatment of Alcohol Withdrawal Syndrome

Benzodiazepines are the first-line treatment for alcohol withdrawal syndrome (AWS), with long-acting benzodiazepines preferred for most patients and intermediate-acting benzodiazepines recommended for patients with liver dysfunction, advanced age, or serious medical comorbidities. 1

Assessment and Severity Determination

• The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale helps evaluate withdrawal severity:

  • <8: Mild withdrawal
  • 8-14: Moderate withdrawal
  • ≥15: Severe withdrawal 1

• Note: CIWA-Ar should not be used alone for diagnosis as high scores may also occur in anxiety disorders, sepsis, hepatic encephalopathy, and severe pain 2, 1

Treatment Algorithm

1. Treatment Setting Decision

• Outpatient management: For mild to moderate withdrawal without serious complications or comorbidities
• Inpatient treatment: Required for cases with:
  • Severe withdrawal
  • History of withdrawal seizures or delirium tremens
  • Significant medical or psychiatric comorbidities
  • Failed outpatient treatment 2

2. Pharmacological Management

First-line: Benzodiazepines

• Long-acting benzodiazepines (preferred for normal liver function):

  • Diazepam: 5-10 mg PO/IV every 6-8 hours 2, 3
    • Advantages: Shortest time to peak effect, facilitates rapid symptom control and accurate titration; long half-life provides smoother withdrawal 4
  • Chlordiazepoxide: 25-100 mg PO every 4-6 hours 2, 5
    • Initial dose for acute withdrawal: 50-100 mg, repeated as needed up to 300 mg/day, then reduced to maintenance levels 5

• Intermediate-acting benzodiazepines (for patients with liver dysfunction, advanced age, or serious comorbidities):

  • Lorazepam: 1-4 mg PO/IV/IM every 4-8 hours 2, 1
    • Starting dose: 6-12 mg/day, tapered following resolution of withdrawal symptoms 2

Symptom-triggered approach (preferred)

• Assess with CIWA-Ar every 1-2 hours
• For severe agitation: Diazepam 5-10 mg IV
• For severe symptoms or seizures: Lorazepam 2-4 mg IV 1

3. Supportive Care

• Thiamine supplementation: 100-300 mg/day for all AWS patients to prevent Wernicke's encephalopathy

  • Continue for 2-3 months after withdrawal resolution 2, 1
  • Administer before giving IV fluids containing glucose 2

• Fluid and electrolyte management:

  • IV normal saline to correct dehydration and hypotension
  • Monitor and correct electrolyte abnormalities, particularly potassium, magnesium, and phosphate 1

4. Management of Complications

• Seizures: Additional benzodiazepine dosing (lorazepam 2-4 mg IV) 1, 6
• Delirium tremens: Continuous monitoring of vital signs, fluid-electrolyte support, respiratory support if needed 6
• Hallucinosis: Benzodiazepines are more effective than antipsychotics 6

Important Considerations and Cautions

• Avoid antipsychotics as standalone treatment for AWS as they may lower seizure threshold 1

• Diazepam safety in liver disease: Despite common concerns, evidence suggests diazepam is safe for AWS treatment in patients with liver disease when using a symptom-based approach 4

• Alternative agents:

  • Carbamazepine (200 mg every 6-8 hours) may be used as an alternative to benzodiazepines for seizure prevention 2
  • Phenobarbital has shown effectiveness comparable to benzodiazepines and may be useful for benzodiazepine-resistant cases 7

• Haloperidol: Use only as adjunctive therapy for agitation or psychotic symptoms not controlled by benzodiazepines (0.5-5 mg PO/IM every 8-12 hours) 2

Long-term Management

• After successful withdrawal management, consider medications to prevent relapse (acamprosate, naltrexone, disulfiram)
• Refer to specialized addiction services and mutual help groups (e.g., Alcoholics Anonymous)
• Consider cognitive-behavioral therapy (CBT) as primary approach for treating alcohol use disorder 1

Discharge patients only when clinically sober and able to safely care for themselves, with appropriate referrals to addiction services for ongoing care 1.