What is the recommended treatment for alcohol withdrawal?

Treatment of Alcohol Withdrawal Syndrome

Benzodiazepines are the gold standard first-line treatment for alcohol withdrawal syndrome due to their efficacy in reducing withdrawal symptoms and preventing seizures and delirium tremens. 1, 2, 3

First-Line Pharmacological Treatment

• Long-acting benzodiazepines (chlordiazepoxide and diazepam) are preferred for most patients as they provide better protection against seizures and delirium due to their longer duration of action 1, 2
• Diazepam is indicated for acute alcohol withdrawal for symptomatic relief of agitation, tremor, impending or acute delirium tremens and hallucinosis 4
• Standard dosing for chlordiazepoxide is 25-100 mg every 4-6 hours orally 5, 1
• Diazepam has the shortest time to peak effect, facilitating rapid symptom control and accurate titration, while its long half-life provides a smoother withdrawal 6

Special Population Considerations

• Lorazepam (intermediate-acting benzodiazepine) is recommended for patients with:
  • Severe AWS
  • Advanced age
  • Recent head trauma
  • Liver failure
  • Respiratory failure
  • Other serious medical comorbidities
  • Obesity 5, 1, 3
• Lorazepam is typically started at 6-12 mg/day and tapered following resolution of withdrawal symptoms 5, 1
• Lorazepam doesn't rely on hepatic oxidation, making it safer for patients with liver impairment 1, 3

Adjunctive Treatments

• Thiamine (100-300 mg/day) must be administered to all AWS patients to prevent Wernicke encephalopathy and maintained for 2-3 months following resolution of withdrawal symptoms 5, 1, 2
• Thiamine should be given before any glucose-containing IV fluids to prevent precipitating acute thiamine deficiency 1, 3
• Carbamazepine (200 mg every 6-8 hours) can be used as an alternative to benzodiazepines for seizure prevention 1, 2
• 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, 3
• Gabapentin can be used to treat mild withdrawal symptoms as an alternative therapy 7

Treatment Setting Determination

• Inpatient treatment is recommended for cases with:
  • Serious complications
  • High levels of recent drinking
  • History of withdrawal seizures or delirium tremens
  • Co-occurring serious medical or psychiatric illness
  • Failure of outpatient treatment 5, 1, 3
• Psychiatric consultation is recommended for evaluation, acute management of AWS, and long-term abstinence planning 5
• Outpatient treatment can be considered for patients with mild to moderate withdrawal symptoms without additional risk factors for developing severe or complicated withdrawal 7

Monitoring and Treatment Duration

• 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 1, 3
• Symptom-triggered regimens are preferred over fixed tapering dose regimens 8
• Treatment with benzodiazepines should be tapered following resolution of withdrawal symptoms 5, 1
• Treatment duration should not exceed 10-14 days to avoid the risk of benzodiazepine dependence 1, 3
• Outpatients should be monitored daily for up to five days after their last drink 7

Common Pitfalls and Caveats

• The CIWA protocol should not be used alone for diagnosis of AWS as high scores may be seen in other conditions such as anxiolytic withdrawal, anxiety disorder, sepsis, hepatic encephalopathy, and severe pain 5, 3
• Disulfiram and naltrexone should be avoided in patients with severe alcoholic liver disease due to potential hepatotoxicity 2, 3
• Neuroleptics used alone can increase the risk of seizures and should only be used as adjuncts to benzodiazepines 9, 10
• Intramuscular diazepam should be avoided due to its lipophilicity resulting in slow absorption; lorazepam or midazolam should be used instead when rapid control of symptoms via IM route is required 6