Management of Alcohol Withdrawal
Benzodiazepines, particularly diazepam, are the first-line treatment for alcohol withdrawal syndrome, with symptom-triggered dosing based on CIWA-Ar scores being the recommended approach. 1, 2
Assessment and Severity Classification
Alcohol withdrawal severity should be assessed using the CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol-Revised) scale:
- Mild withdrawal (CIWA-Ar ≤7): Monitor closely, may not require medication
- Moderate withdrawal (CIWA-Ar 8-14): Initiate benzodiazepine treatment
- Severe withdrawal (CIWA-Ar ≥15): Aggressive benzodiazepine treatment, consider inpatient management 1
Risk factors for severe withdrawal include:
- History of chronic heavy drinking
- Previous withdrawal seizures
- Previous delirium tremens 3
Pharmacological Management
First-Line Treatment: Benzodiazepines
Diazepam is preferred due to:
- Rapid onset of action (facilitates quick symptom control)
- Long half-life (provides self-tapering effect)
- Smoother withdrawal with fewer breakthrough symptoms 4
Diazepam Dosing Protocol:
- Initial dose: 10 mg 3-4 times during first 24 hours
- Subsequent doses: 5 mg 3-4 times daily as needed 1, 2
- Loading dose approach: 20 mg orally every 2 hours until symptoms resolve 5
For symptom-triggered approach:
- CIWA-Ar 8-14: Diazepam 5-10 mg
- CIWA-Ar ≥15: Diazepam 10-20 mg
- Reassess every 1-2 hours and redose as needed 1
Alternative Benzodiazepines
When diazepam is contraindicated:
- Lorazepam: For elderly patients or those with severe liver disease
- Midazolam: When rapid intramuscular administration is required (diazepam has poor IM absorption) 4
Refractory Cases
For patients not responding to standard benzodiazepine therapy:
- Phenobarbital: Effective alternative, particularly in patients who don't respond to benzodiazepines 6
- Propofol: Appropriate for benzodiazepine-refractory cases requiring ICU management 7
Nutritional Support
Thiamine supplementation is essential to prevent Wernicke's encephalopathy:
- Dose: 100-300 mg/day for 4-12 weeks
- Important: Administer thiamine (100 mg) before giving any dextrose-containing solutions 1
Additional nutritional requirements:
- Protein: 1.2-1.5 g/kg/day
- Calories: 35-40 kcal/kg/day 1
Treatment Phases
Initial Phase (1-3 days):
- Manage withdrawal symptoms with benzodiazepines
- Provide thiamine and nutritional support
- Monitor vital signs and withdrawal symptoms
Early Recovery Phase (1-2 weeks):
- Consider pharmacotherapy for alcohol use disorder (naltrexone, acamprosate, or gabapentin)
- Begin psychosocial interventions
Maintenance Phase (3-12 months):
- Continue medications for alcohol use disorder
- Ongoing psychosocial support and regular follow-up 1
Non-Pharmacological Interventions
- Individual support and effective communication reduce risk of severe withdrawal
- Provide a quiet, well-lit environment to minimize sensory disturbances
- Regular monitoring of vital signs and withdrawal symptoms 3
Special Considerations
- Seizures: Benzodiazepines are the treatment of choice for alcohol withdrawal seizures 3
- Delirium tremens: Requires aggressive benzodiazepine treatment, close monitoring of vital signs, and possibly ICU care 3
- Liver disease: Diazepam can still be used safely with symptom-based dosing and careful monitoring 4
Common Pitfalls to Avoid
- Delaying treatment: Prompt initiation of benzodiazepines prevents progression to severe withdrawal 5
- Inadequate dosing: Underdosing benzodiazepines may lead to seizures or delirium tremens
- Overlooking thiamine: Always administer thiamine before glucose to prevent Wernicke's encephalopathy
- Relying on fixed-dose regimens: Symptom-triggered dosing is more effective and reduces medication requirements
- Neglecting hydration status: Monitor and correct fluid and electrolyte imbalances
Protocolized escalation of benzodiazepines may decrease the need for mechanical ventilation and reduce ICU length of stay in severe cases 7.