What is a recommended prn (as needed) medication for agitation in alcohol withdrawal?

PRN Medication for Agitation in Alcohol Withdrawal

Benzodiazepines are the treatment of choice for agitation in alcohol withdrawal, with lorazepam 1-4 mg PO/IV/IM every 4-8 hours being the preferred PRN medication for most patients. 1

First-Line Treatment: Benzodiazepines

Benzodiazepines are specifically indicated as the first-line treatment for alcohol withdrawal syndrome (AWS) due to their effectiveness in managing symptoms and preventing serious complications:

• Benzodiazepines are the treatment of choice as monotherapy for alcohol withdrawal 1
• They help prevent progression to more severe withdrawal symptoms including seizures and delirium tremens 1
• They provide anxiety relief, sedation, and somnolence via activation of gamma-aminobutyric acid (GABA) receptors 1

Recommended Benzodiazepine Options:

1. Lorazepam (Preferred for many patients)

   • Dosing: 1-4 mg PO/IV/IM every 4-8 hours PRN 1
   • Advantages:
     • Intermediate-acting with predictable metabolism 1
     • Safer in patients with liver disease, elderly patients, or those with respiratory issues 2
     • Can be given orally, sublingually, IV, or IM with reliable absorption 1
   • Use lower doses (0.25-0.5 mg) in older/frail patients or those with COPD 1

2. Diazepam

   • Dosing: 5-10 mg PO/IV/IM every 6-8 hours PRN 1
   • FDA-approved specifically for "symptomatic relief of acute agitation, tremor, impending or acute delirium tremens and hallucinosis" in acute alcohol withdrawal 3
   • Advantages:
     • Shortest time to peak effect for rapid symptom control 4
     • Long half-life provides a smoother withdrawal with self-tapering effect 4
   • Caution: May accumulate in patients with liver disease or elderly patients 2

3. Chlordiazepoxide

   • Dosing: 25-100 mg PO every 4-6 hours PRN 1
   • Long-acting with gradual offset of action 1
   • Caution: Avoid in liver disease and elderly patients due to prolonged metabolism 2

Special Considerations

• Patients with liver disease or elderly patients: Prefer lorazepam as it undergoes only glucuronidation rather than oxidative metabolism 2
• When IM administration is required: Use lorazepam as diazepam has erratic IM absorption 4, 2
• Severe agitation: May require higher initial doses with careful monitoring 1

Adjunctive Medications for Agitation

When benzodiazepines alone are insufficient to control agitation or when psychotic symptoms are present:

• Haloperidol: 0.5-5 mg PO/IM every 8-12 hours PRN 1

  • Only as adjunctive therapy for agitation or psychotic symptoms not controlled by benzodiazepines 1
  • Monitor for extrapyramidal side effects and QTc prolongation 1

• Carbamazepine: 200 mg PO every 6-8 hours 1

  • Alternative to benzodiazepines that is effective in seizure prevention 1
  • May be useful in patients with contraindications to benzodiazepines 5

Important Precautions

• Start medications on a PRN basis initially and adjust to scheduled dosing if symptoms persist 1
• Use the lowest effective dose to avoid oversedation and respiratory depression 1
• Monitor for paradoxical agitation which can occasionally occur with benzodiazepines 1
• Always provide thiamine (100-300 mg/day) to prevent Wernicke's encephalopathy 1
• Consider psychiatric consultation for evaluation, treatment, and long-term planning of alcohol abstinence 1