What medications are used to treat alcohol withdrawal symptoms?

Medications for Treating Alcohol Withdrawal Symptoms

Benzodiazepines are the first-line medications for treating alcohol withdrawal syndrome (AWS), with long-acting benzodiazepines like chlordiazepoxide and diazepam being the preferred agents for most patients. 1

First-Line Pharmacological Treatment

• Long-acting benzodiazepines (chlordiazepoxide and diazepam) are recommended for prevention of seizures and management of AWS symptoms through GABA activation 1
• Diazepam is particularly effective due to its short time to peak effect and long elimination half-life, providing smoother withdrawal with lower incidence of breakthrough symptoms 2
• Standard dosing for chlordiazepoxide is 25-100 mg every 4-6 hours 1, 3
• Diazepam dosing for acute alcohol withdrawal is typically 10 mg, 3-4 times during the first 24 hours, reducing to 5 mg, 3-4 times daily as needed 4

Special Population Considerations

• Lorazepam (intermediate-acting benzodiazepine) is recommended for patients with:
  • Severe AWS
  • Advanced age
  • Recent head trauma
  • Liver failure
  • Respiratory failure
  • Other serious medical comorbidities
  • Obesity 1, 3
• Lorazepam is typically started at 6-12 mg/day and tapered following resolution of withdrawal symptoms 1
• For patients with hepatic insufficiency, lorazepam is safer as it doesn't rely on hepatic oxidation 3

Adjunctive Medications

• Thiamine (100-300 mg/day) should be given to all AWS patients to prevent Wernicke encephalopathy, and maintained for 2-3 months following resolution of withdrawal symptoms 1, 3
• Thiamine should be administered before any glucose-containing IV fluids to prevent precipitating acute thiamine deficiency 1
• Carbamazepine (200 mg every 6-8 hours) can be used as an alternative to benzodiazepines for seizure prevention 1, 5
• Haloperidol (0.5-5 mg every 8-12 hours) may be used carefully as adjunctive therapy only for agitation or psychotic symptoms not controlled by benzodiazepines 1
• Other adjunctive treatments for neuroautonomic hyperactivity include α2-agonists (clonidine and dexmedetomidine) and β-blockers 6

Treatment Setting and Monitoring

• Inpatient treatment is recommended for cases with:
  • Serious complications (delirium, seizures)
  • High levels of recent drinking
  • History of withdrawal seizures or delirium tremens
  • Co-occurring serious medical or psychiatric illness
  • Failure of outpatient treatment 1
• Conservative management includes fluids, electrolytes (especially magnesium), vitamins, and a comfortable environment 1
• The CIWA-Ar score can guide treatment intensity—scores >8 indicate moderate AWS and scores ≥15 indicate severe AWS requiring more aggressive treatment 3
• Symptom-triggered regimens are preferred over fixed-dose schedules to prevent drug accumulation while ensuring adequate symptom control 3

Treatment Duration and Discontinuation

• Treatment with benzodiazepines should be tapered following resolution of withdrawal symptoms 1
• Treatment duration should not exceed 10-14 days to avoid the risk of benzodiazepine dependence 3
• Gradual tapering is essential to reduce the risk of withdrawal reactions 4

Common Pitfalls and Caveats

• The CIWA protocol is not recommended for diagnosis of AWS as high scores may be seen in other conditions like anxiolytic withdrawal, anxiety disorder, sepsis, hepatic encephalopathy, and severe pain 1
• Avoid intramuscular administration of diazepam due to its lipophilicity resulting in slow absorption; use lorazepam or midazolam instead when rapid control of symptoms is required 2
• Psychiatric consultation is recommended for evaluation, acute management of AWS, and long-term abstinence planning 1
• Long-term use of benzodiazepines for alcohol dependence is not indicated as controlled studies show it does not improve abstinence rates 7