Diazepam Dosing Chart for Alcohol Withdrawal Management
For alcohol withdrawal, diazepam should be administered at 10 mg, 3 or 4 times during the first 24 hours, reducing to 5 mg, 3 or 4 times daily as needed. 1
Dosing Regimen Based on Withdrawal Severity
Initial Assessment
- Use CIWA-Ar score to determine withdrawal severity:
- Mild: <8
- Moderate: 8-14
- Severe: ≥15 2
Dosing Chart by Severity
Mild Withdrawal (CIWA-Ar <8)
- Monitor without medication or provide:
- Diazepam 5 mg PO every 6-8 hours as needed
Moderate Withdrawal (CIWA-Ar 8-14)
- Diazepam 10 mg PO every 6 hours for 24 hours
- Then reduce to 5 mg PO every 6 hours as needed based on symptoms
Severe Withdrawal (CIWA-Ar ≥15) or Acute Agitation
- Initial dose: 10 mg IV for acute agitation, tremor, or impending delirium tremens
- Maintenance: 5-10 mg IV every 3-4 hours as needed 2
- Alternative: Loading dose approach - 20 mg oral diazepam every 2 hours until asymptomatic 3
Special Populations
Hepatic Dysfunction
- Consider switching to lorazepam instead of diazepam 2
- If using diazepam, reduce initial dose and monitor closely
Elderly or Debilitated Patients
- Initial dose: 2-2.5 mg, 1-2 times daily
- Increase gradually as needed and tolerated 1
Administration Approaches
Symptom-Triggered Approach
- Administer medication based on CIWA-Ar scores
- Reassess scores regularly (every 1-2 hours in severe withdrawal)
- Adjust dosing based on symptom control
Front-Loading Approach
- Higher initial doses followed by scheduled doses
- May decrease need for mechanical ventilation and ICU length of stay 2
- Median of three 20 mg doses (range 1-12 doses) over approximately 7.6 hours has been shown effective 3
Important Adjunctive Treatments
- Thiamine supplementation: 100-300 mg/day IV to prevent Wernicke encephalopathy 2
- Electrolyte replacement (particularly magnesium, potassium, and phosphate)
- Adequate hydration 2
Tapering and Discontinuation
- To reduce withdrawal risk, use a gradual taper when discontinuing diazepam
- If withdrawal reactions develop, consider pausing taper or increasing to previous dosage level
- Subsequently decrease dosage more slowly 1
Clinical Pearls and Pitfalls
- Diazepam has advantages over other benzodiazepines for alcohol withdrawal due to:
- Shortest time to peak effect, allowing rapid symptom control
- Long elimination half-life, providing a smoother withdrawal with self-tapering effect 4
- The fear of increased risk of over-sedation with diazepam compared to other benzodiazepines is unfounded when using a symptom-based approach 4
- Avoid intramuscular administration of diazepam due to its lipophilicity causing slow absorption 4
- Some patients may require surprisingly high doses of benzodiazepines during severe withdrawal; this reflects receptor-site phenomena rather than abnormal drug disposition 5
- Monitor for breakthrough symptoms and seizures, especially in patients with history of multiple withdrawal episodes or previous alcohol withdrawal seizures 2