What is the recommended treatment for alcohol withdrawal?

Treatment for Alcohol Withdrawal Syndrome

Benzodiazepines are the gold standard first-line treatment for alcohol withdrawal syndrome, with long-acting benzodiazepines like diazepam and chlordiazepoxide being preferred for most patients. 1, 2, 3

First-Line Pharmacological Treatment

• Long-acting benzodiazepines (diazepam and chlordiazepoxide) are recommended for prevention of seizures and management of alcohol withdrawal syndrome through GABA activation 1, 2
• Diazepam is administered at 5-10 mg every 6-8 hours orally, intravenously, or intramuscularly for most patients 2
• For acute alcohol withdrawal, diazepam dosing is 10 mg, 3-4 times during the first 24 hours, reducing to 5 mg, 3-4 times daily as needed 4
• Chlordiazepoxide is an alternative option at doses of 25-100 mg every 4-6 hours orally 1, 3
• Diazepam has the shortest time to peak effect, facilitating rapid symptom control and accurate titration, while its long half-life provides a smoother withdrawal with lower risk of breakthrough symptoms 5

Special Population Considerations

• Short and intermediate-acting benzodiazepines (lorazepam, oxazepam) are safer for high-risk patients, including those with:
  • Advanced age
  • Hepatic dysfunction
  • Respiratory failure
  • Obesity
  • Recent head trauma 1, 3
• Lorazepam is typically administered at 1-4 mg every 4-8 hours (6-12 mg/day) and doesn't rely on hepatic oxidation, making it safer for patients with liver impairment 2, 3
• Intramuscular administration of diazepam should be avoided due to slow absorption; lorazepam or midazolam should be used instead when rapid control is needed via this route 5

Adjunctive Treatments

• Thiamine (100-300 mg/day) must be administered to all alcohol withdrawal patients to prevent Wernicke encephalopathy 1, 2
• Thiamine should always 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 or as adjunctive therapy 1, 6
• Haloperidol (0.5-5 mg every 8-12 hours) may be used carefully for agitation or psychotic symptoms not controlled by benzodiazepines 1, 3
• Other adjunctive medications may include α2-agonists (clonidine and dexmedetomidine) and β-blockers to control autonomic hyperactivity 7

Treatment Setting and Monitoring

• 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 1, 3
• The Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA-Ar) can guide treatment intensity:
  • Scores >8 indicate moderate AWS
  • Scores ≥15 indicate severe AWS requiring more aggressive treatment 3, 8
• Patients with mild to moderate withdrawal symptoms without additional risk factors can be treated as outpatients 8
• Outpatients should be monitored daily for up to five days after their last drink 8

Treatment Duration and Discontinuation

• Treatment with benzodiazepines should be tapered following resolution of withdrawal symptoms 1, 3
• Treatment duration should not exceed 10-14 days to avoid the risk of benzodiazepine dependence 1, 3
• To reduce withdrawal reactions, use a gradual taper to discontinue diazepam or reduce the dosage 4

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 1, 3
• Disulfiram and naltrexone should be avoided in patients with severe alcoholic liver disease due to potential hepatotoxicity 2, 3
• Psychiatric consultation is recommended for evaluation, acute management of AWS, and long-term abstinence planning 1
• Treatment of alcohol withdrawal should be followed by treatment for alcohol dependence to prevent recurrence 6, 8