What are the management and medication options for alcohol intoxication?

From the Guidelines

Management of alcohol intoxication involves both supportive care and medication when necessary, with benzodiazepines being the first-line treatment for severe intoxication, especially in cases of alcohol withdrawal or agitation, as recommended by the most recent guidelines 1. For mild to moderate intoxication, the primary approach is supportive care including:

• Monitoring vital signs
• Maintaining hydration with IV fluids if needed
• Ensuring patient safety Benzodiazepines such as diazepam (5-10mg IV) or lorazepam (2-4mg IV) are the preferred medications for severe intoxication, as they enhance GABA activity in the brain, producing a calming effect 1. It is essential to administer thiamine supplementation (100mg IV or IM) before glucose for patients with thiamine deficiency or at risk of Wernicke's encephalopathy, as recommended by recent guidelines 1. Additionally, naloxone (0.4-2mg IV) may be given if opioid co-ingestion is suspected, and anti-emetics such as ondansetron (4-8mg IV) can help manage nausea and vomiting. For severe cases with metabolic acidosis, sodium bicarbonate may be necessary. After acute management, patients should be assessed for alcohol use disorder and referred to appropriate treatment programs, with the goal of stabilizing the patient, preventing complications, and addressing underlying alcohol use issues 1.

From the FDA Drug Label

Diazepam is indicated for the management of anxiety disorders or for the short- term relief of the symptoms of anxiety. In acute alcohol withdrawal, diazepam may be useful in the symptomatic relief of acute agitation, tremor, impending or acute delirium tremens and hallucinosis

The management and medication options for alcohol intoxication are not directly addressed in the label. However, for acute alcohol withdrawal, medication options may include:

• Diazepam for the symptomatic relief of acute agitation, tremor, impending or acute delirium tremens, and hallucinosis 2 Note that diazepam is not explicitly indicated for alcohol intoxication.

From the Research

Management Options for Alcohol Intoxication

• Supportive care is the best therapy to protect the patient from secondary complications 3
• General supportive care of the intoxicated patient is all that is required in most cases 4
• Clinical observation with vital signs control is necessary to evaluate the possible development of the alcohol withdrawal syndrome and to evaluate possible pathological complications of the organism 5

Medication Options for Alcohol Intoxication

• Benzodiazepines, such as lorazepam, chlordiazepoxide, oxazepam, and diazepam, can ameliorate or prevent the symptoms and complications of moderate to severe alcohol withdrawal 6
• Diazepam is the preferred benzodiazepine for the treatment of patients experiencing moderate to severe alcohol withdrawal under most circumstances 6
• In case of severe intoxication, it is necessary to support with intravenous fluids, treat hypoglycemia, hypotension, hypothermia and electrolyte imbalance, administer complex B and C vitamins and accelerate alcohol elimination from blood with metadoxine 5

Special Considerations

• Adolescents are more exposed to the toxic effect of alcohol and acute alcohol-related complications are more frequent and dangerous in young people than in the adult population 5
• Patients affected by acute alcohol intoxication are the best candidates to apply the rules of the Temporary Observation Unit in the Emergency Department, because of a clinical course often completed within 24 hours, a favorable outcome and without the need for hospitalization 5
• The patient affected by Alcohol Use Disorder must be referred to an Alcohol Addiction Unit for the follow-up, to reduce the risk of alcohol relapse and complications related to alcohol abuse, and financial costs of hospitalization 5