From the Guidelines
Propranolol (Inderal) is generally contraindicated in alcohol withdrawal syndrome due to its potential to mask important symptoms without addressing the underlying neurological mechanisms of withdrawal. Beta-blockers like propranolol can hide tachycardia and tremor, which are important clinical indicators of withdrawal severity, without treating the GABA-related central nervous system hyperexcitability that causes seizures and delirium tremens 1. The most recent and highest quality study, published in the Journal of Hepatology in 2018, recommends benzodiazepines as the 'gold standard' treatment for AWS, given their efficacy in reducing both withdrawal symptoms and the risk of seizures and/or delirium tremens 1.
Key Points to Consider
- Benzodiazepines, such as diazepam, lorazepam, or chlordiazepoxide, are the preferred treatment for alcohol withdrawal syndrome due to their ability to directly address GABA receptor dysfunction 1.
- The use of beta-blockers like propranolol may worsen respiratory function in patients with underlying pulmonary disease, which is common in those with alcohol use disorder.
- If blood pressure or heart rate control is needed during withdrawal, other medications like clonidine may be safer alternatives while continuing benzodiazepine therapy as the primary treatment.
- The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) is a useful tool in clinical practice for assessing the severity of alcohol withdrawal syndrome, with a score >8 indicating moderate AWS and a score ≥15 indicating severe AWS 1.
Treatment Approach
- Benzodiazepines should be administered on a symptom-triggered basis or fixed-schedule regimen with appropriate monitoring of vital signs and withdrawal symptoms using validated tools like the CIWA-Ar scale 1.
- Clinicians should avoid the use of benzodiazepines and clomethiazole beyond the initial 10–14 days of treatment due to the potential risk of abuse 1.
- Other drugs, such as baclofen and sodium oxybate, have been tested in the treatment of AWS and may have additional value in treating AUD 1.
From the Research
Pharmacological Treatment of Alcohol Withdrawal
The use of propranolol (Inderal) in alcohol withdrawal syndrome is discussed in several studies:
- According to 2, beta blockers, including propranolol, are useful in combating hypertension and tachycardia associated with alcohol withdrawal.
- However, beta blockers are ineffective as anticonvulsants, and benzodiazepines are preferred for their high degree of efficacy and safety in treating alcohol withdrawal syndrome 2.
- In the treatment of severe alcohol withdrawal, adjunctive agents such as phenobarbital, dexmedetomidine, and propofol may be used, but the role of beta blockers like propranolol is not clearly defined 3.
- The primary treatment for alcohol withdrawal syndrome remains benzodiazepines, with other agents like anticonvulsants, adrenergic alpha-2 agonists, beta blockers, and antipsychotics used in combination with benzodiazepines for symptom reduction in severe cases 4.
Contraindications and Precautions
While the studies do not directly state that propranolol is contraindicated in alcohol withdrawal syndrome, they do emphasize the importance of careful clinical assessment and the potential for coexisting medical problems to complicate treatment 2.
- The use of beta blockers like propranolol may be limited by their lack of anticonvulsant properties and potential interactions with other medications 2.
- The treatment of alcohol withdrawal syndrome should be individualized, taking into account the patient's medical history, severity of symptoms, and potential for complications 4, 5, 3.