Librium (Chlordiazepoxide) Dosing for Mild Alcohol Withdrawal
For mild alcohol withdrawal, chlordiazepoxide (Librium) should be administered orally at 25-100 mg every 4-6 hours in a tapering regimen over 3-7 days. 1
Dosing Regimen
Initial Dosing
- For mild alcohol withdrawal symptoms, start with chlordiazepoxide 25-50 mg orally every 6 hours for the first day 1, 2
- For moderate symptoms, start with 50-100 mg orally every 6 hours 1
- Dosage should be individualized based on symptom severity, with higher doses for more severe symptoms 2
Tapering Schedule
- Day 1: 25-50 mg every 6 hours (total: 100-200 mg/day) 1, 2
- Day 2: 25 mg every 6 hours (total: 100 mg/day) 2
- Day 3: 25 mg every 8 hours (total: 75 mg/day) 2
- Day 4: 25 mg every 12 hours (total: 50 mg/day) 2
- Day 5: 25 mg at bedtime 2
- Day 6-7: Discontinue 2
Monitoring and Assessment
- Use the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale to assess withdrawal severity; scores >8 indicate moderate withdrawal and ≥15 indicate severe withdrawal 1
- A symptom-triggered regimen is preferred over fixed-dose schedule to prevent medication accumulation 1
- Monitor vital signs, mental status, and withdrawal symptoms regularly 1
Special Considerations
- Thiamine supplementation (100-300 mg/day) should be given to all patients with alcohol withdrawal syndrome to prevent Wernicke encephalopathy 1
- Administer thiamine before giving any glucose-containing fluids to prevent precipitating acute thiamine deficiency 1
- For patients with liver dysfunction, advanced age, or respiratory issues, consider lorazepam (1-4 mg every 4-8 hours) instead of chlordiazepoxide 1, 3
- Ensure adequate hydration and electrolyte replacement, especially magnesium 1
Treatment Setting
- Mild withdrawal can typically be managed in outpatient settings 1
- Consider inpatient treatment for patients with:
- History of withdrawal seizures or delirium tremens
- Significant medical or psychiatric comorbidities
- Failed outpatient treatment
- High levels of recent drinking 1
Clinical Pearls
- Benzodiazepines are the gold standard for alcohol withdrawal treatment due to their efficacy in reducing symptoms and preventing seizures and delirium tremens 1
- Long-acting benzodiazepines like chlordiazepoxide provide more protection against seizures and delirium compared to short-acting ones 1
- Avoid using benzodiazepines beyond 10-14 days due to potential for abuse 1
- Most outpatients with mild to moderate withdrawal without complications can improve with supportive care, but medication significantly reduces risk of complications 4
- Delay in therapy may be responsible for complications in alcohol withdrawal 5
Adjunctive Treatments
- 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) may be used carefully as adjunctive therapy only for agitation or psychotic symptoms not controlled by benzodiazepines 1
- Psychiatric consultation is recommended for evaluation, treatment, and long-term planning of alcohol abstinence 1