What is the recommended treatment for alcohol withdrawal?

Treatment of Alcohol Withdrawal Syndrome

Benzodiazepines are the first-line treatment for alcohol withdrawal syndrome, with diazepam being the preferred agent for most patients due to its rapid onset of action and long half-life that provides a self-tapering effect. 1, 2

Assessment and Severity Stratification

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

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

• Risk factors for severe withdrawal:

  • Chronic heavy drinking
  • History of seizures or delirium tremens
  • Comorbid liver disease 1, 3

Pharmacological Management

First-Line Treatment: Benzodiazepines

1. Diazepam (preferred):

   • Dosing: 5-10 mg PO/IV every 6-8 hours 1
   • FDA-approved for acute alcohol withdrawal 2
   • Advantages: Rapid onset, long half-life providing smooth withdrawal 4
   • Can be administered using symptom-triggered approach based on CIWA-Ar scores 1

2. Alternative Benzodiazepines:

   • Lorazepam: 1-4 mg PO/IV/IM every 4-8 hours (preferred for patients with liver dysfunction, advanced age, or serious comorbidities) 1
   • Chlordiazepoxide: 25-100 mg PO every 4-6 hours 1

Adjunctive Treatments

1. Thiamine supplementation:

   • 100-300 mg/day for all patients with alcohol withdrawal
   • Continue for 2-3 months after resolution of withdrawal symptoms
   • Prevents Wernicke encephalopathy 1

2. For agitation/psychotic symptoms not controlled by benzodiazepines:

   • Haloperidol: 0.5-5 mg PO/IM every 8-12 hours
   • Note: Antipsychotics should not be used as standalone treatment 1

3. For mild withdrawal symptoms:

   • Carbamazepine or gabapentin can be considered 5

Treatment Approach Based on Setting

Outpatient Management (for mild-moderate withdrawal)

• Appropriate for patients at low risk of developing severe withdrawal syndrome 3
• Daily monitoring for up to five days after last drink 5
• Symptom-triggered benzodiazepine therapy based on CIWA-Ar scores 1
• Close personal support and communication in a reassuring environment 3

Inpatient Management (for moderate-severe withdrawal)

• Required for patients with:

  • Severe withdrawal symptoms (CIWA-Ar ≥15)
  • History of withdrawal seizures or delirium tremens
  • Significant medical comorbidities
  • Inability to follow outpatient instructions 1, 3

• Delirium tremens management:

  • Always requires inpatient care, often in ICU
  • IV fluids (normal saline) to correct dehydration
  • Electrolyte monitoring and correction (especially potassium, magnesium, phosphate)
  • Continuous monitoring of vital signs 1

Diazepam Loading Technique

• An effective approach for moderate-severe withdrawal
• Initial dose of 20 mg oral diazepam, repeated every 1-2 hours until symptoms resolve
• Takes advantage of diazepam's long half-life for a self-tapering effect 6
• Median requirement: three 20-mg doses over approximately 7.6 hours 6

Post-Withdrawal Management

• Consider medications to prevent relapse:

  • Acamprosate
  • Naltrexone (avoid in patients with alcoholic liver disease)
  • Disulfiram 1

• Refer to specialized addiction services and mutual help groups (e.g., Alcoholics Anonymous)

• Consider cognitive-behavioral therapy 1

• Psychiatric consultation for evaluation, treatment, and long-term planning 1

Common Pitfalls to Avoid

1. Undertreatment: Inadequate dosing of benzodiazepines can lead to progression to seizures or delirium tremens 3

2. Overreliance on CIWA-Ar: High scores may also occur in anxiety disorders, sepsis, hepatic encephalopathy, and severe pain 1

3. Using neuroleptics alone: Increases seizure risk; should only be used as adjuncts to benzodiazepines 3

4. Prolonged benzodiazepine treatment: Long-term use beyond withdrawal management is not recommended 7

5. Neglecting thiamine supplementation: Can lead to Wernicke encephalopathy, a medical emergency 3