What is the recommended management for alcohol withdrawal?

Management of Alcohol Withdrawal Syndrome

Benzodiazepines are the gold standard treatment for alcohol withdrawal syndrome (AWS) due to their efficacy in reducing withdrawal symptoms and preventing serious complications such as seizures and delirium tremens. 1, 2

Initial Assessment and Treatment Setting

• AWS typically develops within 6-24 hours after the last drink with symptoms including increased blood pressure, tachycardia, tremors, hyperreflexia, irritability, anxiety, headache, nausea, and vomiting 1
• Inpatient treatment is strongly recommended for cases with serious complications such as delirium, seizures, or significant physical/psychological comorbidities 1, 2
• The CIWA-Ar score can guide treatment intensity—scores >8 indicate moderate AWS and scores ≥15 indicate severe AWS requiring more aggressive treatment, though this score should not be used for diagnosis 1, 2

First-Line Pharmacological Treatment

• Long-acting benzodiazepines (diazepam, chlordiazepoxide) are preferred for most patients due to:

  • Shorter time to peak effect, facilitating rapid symptom control 2, 3
  • Longer elimination half-lives providing a smoother, self-tapering withdrawal 3
  • Greater protection against seizures and delirium 1

• Diazepam dosing:

  • 5-10 mg every 6-8 hours orally, intravenously, or intramuscularly 2, 4
  • For acute alcohol withdrawal, diazepam is indicated for symptomatic relief of agitation, tremor, impending or acute delirium tremens and hallucinosis 4

• Chlordiazepoxide dosing:

  • For severe anxiety and symptoms: 20-25 mg, 3-4 times daily 5
  • For withdrawal symptoms: initial dose 50-100 mg, followed by repeated doses as needed until agitation is controlled (up to 300 mg per day), then reduced to maintenance levels 5

Special Population Considerations

• Short and intermediate-acting benzodiazepines (lorazepam, oxazepam) are safer in:

  • Elderly patients 1, 2
  • Patients with hepatic dysfunction 1, 2
  • Patients with respiratory failure or obesity 2

• Lorazepam dosing:

  • Start at 6-12 mg/day (1-4 mg every 4-8 hours) and taper following resolution of withdrawal symptoms 1, 2

Adjunctive Treatments

• Thiamine (100-300 mg/day) must be administered to all patients with AWS to prevent Wernicke encephalopathy and should be maintained for 2-3 months following resolution of withdrawal symptoms 1, 2

• For benzodiazepine-refractory cases, consider:

  • Propofol for patients not responding to benzodiazepines 6
  • Phenobarbital as an alternative or adjunct to benzodiazepines, particularly in patients with history of AWS complications 7
  • Carbamazepine (200 mg every 6-8 hours) as an alternative for seizure prevention 2, 8

Treatment Duration and Monitoring

• Benzodiazepine treatment should not exceed 10-14 days to avoid the risk of dependence 2
• Protocolized escalation of benzodiazepines may decrease the need for mechanical ventilation and ICU length of stay compared to purely symptom-triggered approaches 6
• Monitor vital signs frequently, especially in patients with severe AWS 1

Common Pitfalls and Caveats

• The fear of increased risk of over-sedation with diazepam compared to other benzodiazepines is often unfounded when administered using a symptom-based approach 3
• Avoid intramuscular administration of diazepam due to its lipophilicity resulting in slow absorption; use lorazepam or midazolam instead when rapid control is needed via IM route 3
• Disulfiram should be avoided in patients with severe alcoholic liver disease due to potential hepatotoxicity 1
• Psychiatric consultation is recommended for evaluation, acute management, and long-term abstinence planning 1