What is the treatment for a patient with alcohol withdrawal (alcohol w/d) agitation?

Treatment for Alcohol Withdrawal Agitation

Benzodiazepines are the gold standard first-line treatment for alcohol withdrawal agitation, with specific agent selection based on patient characteristics. 1, 2

First-Line Pharmacological Treatment

• Benzodiazepines are the most effective medications for managing alcohol withdrawal syndrome (AWS) due to their efficacy in reducing agitation, preventing seizures, and preventing delirium tremens 3, 1
• Long-acting benzodiazepines are preferred for most patients:
  • Diazepam: 5-10 mg PO/IV/IM every 6-8 hours 2, 4
  • Chlordiazepoxide: 25-100 mg PO every 4-6 hours 3, 5
• These agents provide better protection against seizures and delirium due to their longer duration of action and self-tapering effect 6

Special Population Considerations

• Lorazepam (intermediate-acting benzodiazepine) is recommended for high-risk patients including those with:
  • Advanced age
  • Liver failure
  • Respiratory failure
  • Obesity
  • Recent head trauma 3, 2
• Lorazepam dosing: 1-4 mg PO/IV/IM every 4-8 hours (typically 6-12 mg/day) 3, 5
• Lorazepam doesn't rely on hepatic oxidation, making it safer for patients with liver impairment 5, 6

Adjunctive Treatments

• Thiamine (100-300 mg/day) must be administered to all patients with alcohol withdrawal to prevent Wernicke encephalopathy 3, 2
• Thiamine should be given before any glucose-containing IV fluids to prevent precipitating acute thiamine deficiency 2
• For agitation not controlled by benzodiazepines:
  • Haloperidol: 0.5-5 mg PO/IM every 8-12 hours as adjunctive therapy only for agitation or psychotic symptoms 3, 2
• Alternative for seizure prevention:
  • Carbamazepine: 200 mg PO every 6-8 hours 3, 7

Treatment Setting Determination

• Inpatient treatment is recommended 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 3, 5
• Psychiatric consultation is recommended for evaluation, treatment, and long-term planning of alcohol abstinence 3, 2

Supportive Care

• Provide fluids, electrolytes (especially magnesium), vitamins, and a comfortable environment 3, 8
• Monitor vital signs regularly to assess autonomic hyperactivity 8, 7

Treatment Duration and Monitoring

• Benzodiazepines should be tapered following resolution of withdrawal symptoms 3, 5
• Treatment duration typically should not exceed 10-14 days to avoid the risk of benzodiazepine dependence 5
• The Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA-Ar) can guide treatment intensity—scores >8 indicate moderate AWS and scores ≥15 indicate severe AWS requiring more aggressive treatment 5, 2

Common Pitfalls and Caveats

• Delaying benzodiazepine therapy may lead to complications including progression to delirium tremens 9
• Avoid using the CIWA protocol alone for diagnosis of AWS as high scores may be seen in other conditions 2
• For patients requiring intramuscular administration, lorazepam is preferred over diazepam due to diazepam's lipophilicity causing slow absorption 6
• Thiamine deficiency is common in alcohol use disorder and must be addressed to prevent neurological complications 3, 7