Should we prescribe gabapentin with benzodiazepines (BZDs) during alcohol withdrawal or should benzodiazepines be omitted first?

Gabapentin and Benzodiazepines in Alcohol Withdrawal Management

Benzodiazepines should remain the first-line treatment for alcohol withdrawal, with gabapentin potentially serving as an adjunctive therapy rather than a replacement. 1, 2

Assessment and Initial Management

• Assess withdrawal severity using the CIWA-Ar score:

  • Mild (≤7): Monitor, may not require medication
  • Moderate (8-14): Initiate benzodiazepine treatment
  • Severe (≥15): Aggressive benzodiazepine treatment, consider inpatient management 1

• Benzodiazepine protocol:

  • Diazepam 10 mg 3-4 times during first 24 hours
  • Reduce to 5 mg 3-4 times daily as needed 1

Role of Gabapentin in Alcohol Withdrawal

Current Evidence

• Gabapentin has shown efficacy for alcohol use disorder (AUD) treatment at a target dose of 1800 mg/day (600 mg three times daily) 1
• However, research on gabapentin for acute alcohol withdrawal shows mixed results:
  • Some retrospective data suggests benefit in mild to moderate withdrawal 3
  • More recent studies found gabapentin did not reduce benzodiazepine requirements and may be associated with higher CIWA-Ar scores 4
  • A 2022 meta-analysis concluded there is insufficient evidence to support widespread use of gabapentin alone for inpatients with alcohol withdrawal syndrome 5

Practical Approach

1. Do not omit benzodiazepines initially:

   • Benzodiazepines remain the gold standard for alcohol withdrawal treatment 2
   • They effectively reduce withdrawal seizure risk with strong evidence 2

2. Consider gabapentin as adjunctive therapy:

   • May be beneficial once acute withdrawal symptoms are controlled with benzodiazepines
   • Initiate at 300 mg at bedtime on Day 1,300 mg twice daily on Day 2, and 300 mg three times daily on Day 3 1
   • Target dose: 1800 mg/day (600 mg three times daily) 1

3. Potential benefits of adjunctive gabapentin:

   • May help in transition from benzodiazepines
   • Could reduce total benzodiazepine requirements in some patients 6
   • Beneficial for ongoing AUD management after acute withdrawal 1

Special Considerations

• Gabapentin advantages:

  • No hepatic metabolism (75% renally excreted)
  • May be safer in patients with liver concerns 1
  • No abuse potential compared to benzodiazepines 3

• Cautions:

  • Requires dose adjustment in renal impairment 1
  • May not be sufficient as monotherapy for moderate to severe withdrawal 4, 5
  • Monitor for sedation when combined with benzodiazepines

Common Pitfalls to Avoid

1. Substituting gabapentin for benzodiazepines in moderate to severe withdrawal (increases seizure risk)
2. Failing to provide adequate benzodiazepine dosing during acute withdrawal phase
3. Not adjusting gabapentin dose in patients with renal impairment
4. Overlooking nutritional support (thiamine 100-300 mg/day) which is essential to prevent Wernicke's encephalopathy 1