Management of Alcohol Withdrawal Syndrome
Benzodiazepines should be used as first-line treatment for alcohol withdrawal syndrome (AWS), with long-acting benzodiazepines preferred for most patients and intermediate-acting options for those with liver dysfunction or other comorbidities. 1
Initial Assessment and Treatment Setting
- Psychiatric consultation is recommended for evaluation, acute management, and long-term planning of alcohol abstinence 1
- Inpatient treatment is indicated for patients with:
- Significant AWS symptoms
- High levels of recent drinking
- History of withdrawal seizures or delirium tremens
- Co-occurring serious medical or psychiatric illness
- Failure of outpatient treatment 1
- Outpatient treatment may be more cost-effective for patients at low risk of developing severe withdrawal syndrome, though abstinence rates are similar at 6 months 1, 2
Pharmacological Management
First-Line Treatment: Benzodiazepines
- Long-acting benzodiazepines (chlordiazepoxide and diazepam) are preferred for most patients due to their efficacy in preventing seizures 1, 2
- Diazepam dosing for acute alcohol withdrawal: 10 mg, 3-4 times during the first 24 hours, reducing to 5 mg, 3-4 times daily as needed 3
- Chlordiazepoxide standard dosing: 25-100 mg every 4-6 hours, typically in a decremental fixed-dose regimen over 9-10 days 4
- Lorazepam (intermediate-acting) is recommended for patients with:
- Lorazepam starting dosage: 6-12 mg/day, tapered following resolution of withdrawal symptoms 1
Dosing Approaches
- Symptom-triggered regimens are preferred over fixed-dose schedules to prevent drug accumulation while ensuring adequate symptom control 4, 5
- Treatment duration should not exceed 10-14 days to avoid the risk of benzodiazepine dependence 4
- Diazepam loading (20 mg oral every 2 hours until asymptomatic) can simplify treatment by taking advantage of the drug's long half-life and metabolites 6
Alternative Medications
- Carbamazepine (200 mg every 6-8 hours) can be used as an alternative to benzodiazepines for seizure prevention 1
- Haloperidol (0.5-5 mg every 8-12 hours) should be used carefully as adjunctive therapy only for agitation or psychotic symptoms not controlled by benzodiazepines 1
- Propofol may be appropriate for patients refractory to benzodiazepines, though the roles of phenobarbital, dexmedetomidine, and ketamine remain unclear 7
Supportive Care
- Thiamine supplementation is essential for all AWS patients:
- Thiamine should be given before administering IV fluids containing glucose to prevent precipitating acute thiamine deficiency 1
- Provide fluids, electrolytes (especially magnesium), and maintain a comfortable environment 1
- Monitor vital signs and withdrawal symptoms frequently, especially during the first 72 hours when symptoms are most likely to escalate 4
Long-Term Management
- Alcohol abstinence is the most important treatment for patients with alcoholic liver disease, improving survival, prognosis, and preventing progression to cirrhosis 1
- Psychiatric consultation is recommended for long-term planning of alcohol abstinence 1
- For maintenance of abstinence, acamprosate has shown efficacy in multiple trials 1
- Disulfiram should be avoided in patients with severe alcoholic liver disease due to potential hepatotoxicity 1
Common Pitfalls and Caveats
- The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol is not recommended for diagnosis of AWS, as high scores may be seen in other conditions like anxiety disorders, sepsis, hepatic encephalopathy, and severe pain 1
- Neuroleptics used alone increase the risk of seizures and should be avoided as primary treatment 2
- Delay in therapy may be responsible for the appearance of complications in alcohol withdrawal 6
- Betablockers increase the risk of hallucinations, and clonidine increases the risk of nightmares 2
- Excessive water-sodium intake carries a risk of pulmonary edema in patients with heart disease 2