What medications are given in alcohol withdrawal?

Medications for Alcohol Withdrawal Management

Benzodiazepines are the first-line medications for managing alcohol withdrawal, with thiamine supplementation required for all patients to prevent neurological complications. 1, 2, 3

First-Line Medications

• Benzodiazepines are the gold standard for alcohol withdrawal treatment, helping to alleviate withdrawal discomfort and preventing serious complications like seizures and delirium tremens 1, 2, 3
• Long-acting benzodiazepines (diazepam, chlordiazepoxide) provide better protection against seizures and delirium due to their gradual self-tapering effect 3, 4
• Short and intermediate-acting benzodiazepines (lorazepam, oxazepam) are preferred for elderly patients or those with hepatic dysfunction 3
• Diazepam has the shortest time to peak effect, facilitating rapid symptom control and accurate titration to avoid over-sedation 4

Dosing Considerations

• For chlordiazepoxide, the suggested initial dose for alcohol withdrawal is 50 to 100 mg, followed by repeated doses as needed until agitation is controlled—up to 300 mg per day, then reduced to maintenance levels 5
• Benzodiazepine treatment should be limited to 7-14 days to minimize the risk of dependence 3, 6
• Symptom-triggered medication regimens are recommended rather than fixed-dose schedules to prevent drug accumulation 3, 7

Essential Adjunctive Therapy

• All patients undergoing alcohol withdrawal must receive thiamine supplementation 1, 2, 3
• Oral thiamine should be given to all patients; parenteral thiamine is indicated for high-risk patients (malnourished, severe withdrawal) or those with suspected Wernicke's encephalopathy 1, 2

Medications to Avoid or Use with Caution

• Antipsychotics should not be used as stand-alone medications for alcohol withdrawal management 1, 2
• Antipsychotics may be used as adjuncts to benzodiazepines only in severe withdrawal delirium that has not responded to adequate benzodiazepine doses 1, 2
• Anticonvulsants should not be used following an alcohol withdrawal seizure for prevention of further seizures 1

Treatment Setting Considerations

• Inpatient management is recommended for patients at risk of severe withdrawal, those with concurrent serious physical or psychiatric disorders, or those lacking adequate support 1, 2, 3
• Psychoactive medications used for withdrawal should be dispensed in small quantities or each dose supervised to reduce misuse risk 1

Relapse Prevention Medications

• After acute withdrawal management, acamprosate, disulfiram, or naltrexone should be offered to reduce relapse in alcohol-dependent patients 1, 2
• The choice among these medications should consider patient preferences, motivation, and availability 1

Common Pitfalls to Avoid

• Prescribing benzodiazepines for longer than necessary (beyond 7-14 days) increases dependence risk 2, 6
• Overlooking the need for thiamine supplementation can lead to Wernicke's encephalopathy, a preventable neurological emergency 2, 3
• Using antipsychotics as primary treatment increases seizure risk 6
• Failing to recognize severe withdrawal requiring inpatient management can lead to increased morbidity and mortality 1, 2