What is the recommended treatment for alcohol withdrawal in adults?

Treatment of Alcohol Withdrawal in Adults

Benzodiazepines are the first-line treatment for alcohol withdrawal in adults, with diazepam being the preferred option due to its rapid onset and long half-life, providing smoother withdrawal and decreased risk of breakthrough symptoms. 1, 2

Assessment and Severity Stratification

• Use the CIWA-Ar scale to evaluate withdrawal severity:

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

• Assess for:

  • Vital sign instability
  • History of withdrawal seizures or delirium tremens
  • Comorbid conditions, especially liver disease
  • Mental status changes using validated tools (Richmond Agitation Sedation Scale or Glasgow Coma Scale) 1

Pharmacological Management

First-Line Treatment: Benzodiazepines

1. Diazepam (preferred option):

   • Dosing: 5-10 mg PO/IV every 6-8 hours
   • Advantages: Rapid symptom control, smoother withdrawal due to long half-life, self-tapering effect 1, 2, 3
   • FDA-approved for acute alcohol withdrawal 2

2. Chlordiazepoxide (alternative):

   • Dosing: 25-100 mg PO every 4-6 hours
   • For acute alcoholism withdrawal: Initial dose 50-100 mg, repeated as needed up to 300 mg per day, then reduced to maintenance levels 1, 4

3. Lorazepam (preferred in liver dysfunction):

   • Dosing: 1-4 mg PO/IV/IM every 4-8 hours
   • Simpler metabolism makes it safer in hepatic impairment 1

Dosing Approach

• Symptom-triggered dosing based on CIWA-Ar scores is recommended
• Initial dose: 6-12 mg/day, tapered following symptom resolution
• For severe withdrawal: Higher doses may be required with close monitoring 1

Alternative and Adjunctive Agents

• Carbamazepine: 200 mg every 6-8 hours (alternative for seizure prevention) 1, 5
• Haloperidol: 0.5-5 mg PO/IM every 8-12 hours (for agitation/psychotic symptoms not controlled by benzodiazepines)
  • Note: Antipsychotics should NOT be used as standalone treatment as they may lower seizure threshold 1
• Clonidine: 0.1-0.2 mg every 6-8 hours (as part of benzodiazepine-sparing protocols)
  • Monitor for hypotension and bradycardia 1

Supportive Care

1. Thiamine supplementation:

   • Dose: 100-300 mg/day for all alcohol withdrawal patients
   • Administer before glucose-containing IV fluids
   • Continue for 2-3 months after withdrawal resolution 1

2. Fluid and electrolyte management:

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

Management of Severe Withdrawal

Delirium Tremens (DT)

• Typically begins 48-72 hours after last alcohol drink
• Symptoms: Increased blood pressure and pulse, tremors, hyperreflexia, irritability, anxiety, headache, nausea, vomiting
• Management:
  • Requires inpatient management, often in ICU
  • Aggressive benzodiazepine treatment (diazepam preferred)
  • Supportive care with IV fluids, electrolyte correction, and thiamine 1

Seizures

• For withdrawal seizures: Oral benzodiazepines are the best-assessed treatment 1, 6

Indications for Hospital Referral

Immediate hospital referral is necessary for:

• CIWA-Ar score ≥15
• Seizure activity
• Hallucinations
• Significant vital sign abnormalities
• Inability to take oral medications
• Inadequate home support 1

Post-Withdrawal Management

After successful withdrawal management:

• Consider medications to prevent relapse (acamprosate, naltrexone)
• Naltrexone (50 mg once daily) can be safely continued during benzodiazepine-managed withdrawal 1
• Refer to specialized addiction services and support groups
• Consider cognitive-behavioral therapy (CBT) 1

Important Considerations and Pitfalls

• Do not use antipsychotics as standalone treatment for alcohol withdrawal
• Avoid prolonged benzodiazepine use due to addiction risk
• Do not treat anxiety without addressing alcohol use, as treatment of anxiety alone rarely resolves alcoholism 1
• Recognize that home detox is only suitable for patients with no history of delirium tremens, reliable support, ability to take medication as prescribed, and no significant medical comorbidities 1
• Be aware that benzodiazepines have consistently shown superiority over other agents in preventing withdrawal-related mortality 6