Management of Alcohol Withdrawal and Promoting Abstinence in Patients with Liver Dysfunction
For patients with liver dysfunction due to alcohol abuse, lorazepam is the preferred benzodiazepine for managing alcohol withdrawal syndrome, while baclofen is the recommended medication for promoting abstinence. 1, 2
Alcohol Withdrawal Management
Initial Assessment and Hospitalization Criteria
- Psychiatric consultation is recommended for evaluation, treatment, and long-term planning of alcohol abstinence 1
- Inpatient treatment is indicated for:
- Significant alcohol withdrawal syndrome
- High levels of recent drinking
- History of withdrawal seizures or delirium tremens
- Co-occurring serious medical or psychiatric illness
- Liver failure
- Failure of outpatient treatment 1
Pharmacological Management of Withdrawal
Benzodiazepine Selection
- Lorazepam (1-4 mg PO/IV/IM every 4-8 hours) is the preferred benzodiazepine for patients with liver failure 1, 2
- For patients with severe AWS, advanced age, liver failure, or respiratory failure, lorazepam should be started at 6-12 mg/day and tapered following resolution of withdrawal symptoms 1
- Avoid chlordiazepoxide in liver dysfunction as its metabolism occurs through hepatic oxidation, which can be markedly delayed in hepatic insufficiency, potentially leading to "dose-stacking" and delayed, profound sedation 3
Supportive Care
- Thiamine supplementation:
- 100-300 mg/day for 4-12 weeks to prevent Wernicke encephalopathy
- Should be given before administering IV fluids containing glucose 1
- Provide fluids, electrolytes (especially magnesium), and a comfortable environment 1
Alternative Medications
- Carbamazepine (200 mg PO every 6-8 hours) can be considered as an alternative to benzodiazepines for seizure prevention 1
- Haloperidol (0.5-5 mg PO/IM every 8-12 hours) may be used carefully as adjunctive therapy only for agitation or psychotic symptoms not controlled by benzodiazepines 1
Promoting Long-term Abstinence
Pharmacological Options
First-line for Patients with Liver Dysfunction
- Baclofen (GABAB receptor agonist):
Other Medication Options
- Acamprosate:
- Reduces withdrawal effects and alcohol craving
- Initiated 3-7 days after last alcohol consumption and after withdrawal symptoms resolve
- Dosage: 1,998 mg/day for patients ≥60 kg; reduced by one-third for patients <60 kg
- Treatment period: 3-6 months 1
- Naltrexone:
- Disulfiram:
- ALDH inhibitor causing unpleasant symptoms when alcohol is consumed
- Currently not commonly used due to potential adverse effects 1
Psychosocial Treatment
- Psychological support focusing on the environment, reasons, and consequences of drinking 1
- Family and group therapy should accompany pharmacological treatment 1
Important Considerations and Pitfalls
- In patients with liver dysfunction, benzodiazepines should be used cautiously with monitoring due to risk of excessive sedation or precipitating hepatic encephalopathy 2
- The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol may not be reliable for diagnosis of AWS as high scores can be seen in conditions similar to AWS, such as hepatic encephalopathy 1
- Alcohol abstinence is the most important treatment for patients with alcoholic liver disease as it improves survival, prognosis, and prevents progression to cirrhosis 1
- Thiamine should always be given before administering glucose-containing IV fluids to prevent precipitating acute thiamine deficiency 1
- Careful monitoring of vital signs and evaluation of comorbidities such as dehydration, electrolyte imbalance, renal failure, and gastrointestinal bleeding is essential 1