From the Guidelines
Alcohol withdrawal medication should be initiated as soon as withdrawal symptoms appear, typically within 6-24 hours after the last drink, with a symptom-triggered regimen using benzodiazepines for moderate and severe cases, as indicated by a CIWA-Ar score >8. When managing alcohol withdrawal syndrome (AWS), it is crucial to assess the severity of symptoms using the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale 1.
- A CIWA-Ar score >8 indicates a moderate AWS, and a score ≥15 indicates severe AWS, both of which require pharmacological treatment.
- Benzodiazepines, such as diazepam, chlordiazepoxide, and lorazepam, are considered the 'gold standard' treatment for AWS due to their efficacy in reducing withdrawal symptoms and the risk of seizures and/or delirium tremens 1.
- The choice of benzodiazepine depends on the patient's condition, with long-acting benzodiazepines providing more protection against seizures and delirium, but short and intermediate-acting benzodiazepines being safer in elderly patients and those with hepatic dysfunction 1.
- A symptom-triggered regimen is recommended, where medication is given based on symptoms assessed using the CIWA-Ar scale, rather than a fixed dose schedule, to prevent the accumulation of the drug 1.
- Other medications, such as baclofen and sodium oxybate, have been tested in the treatment of AWS, but their use is not as established as benzodiazepines 1.
- It is essential to note that benzodiazepines carry a potential risk of abuse, and their use should be limited to the initial 10-14 days of treatment 1.
From the FDA Drug Label
DOSAGE AND ADMINISTRATION ... Symptomatic Relief in Acute Alcohol Withdrawal. 10 mg, 3 or 4 times during the first 24 hours, reducing to 5 mg, 3 or 4 times daily as needed The medication for alcohol withdrawal syndrome, diazepam, should be initiated when symptoms of acute alcohol withdrawal are present.
- The initial dose is 10 mg, 3 or 4 times during the first 24 hours.
- The dosage can be reduced to 5 mg, 3 or 4 times daily as needed after the first 24 hours. 2
From the Research
Initiation of Medication for Alcohol Withdrawal Syndrome
- Medication for alcohol withdrawal syndrome should be initiated at the onset of symptoms and continued until symptoms subside 3.
- The Clinical Institute Withdrawal Assessment Scale-Alcohol Revised (CIWA-Ar) is used to assess the severity of alcohol withdrawal syndrome, and a score of more than 8 indicates the need for pharmacotherapy 4.
- Benzodiazepines are the preferred agents for the management of alcohol withdrawal syndrome, and they should be given at the onset of symptoms to minimize symptoms and prevent complications 3, 5, 6.
- In patients with severe alcohol withdrawal syndrome or those at high risk of complications, medication should be initiated promptly, and the patient should be closely monitored 3, 5, 4.
Factors to Consider When Initiating Medication
- The severity of alcohol withdrawal syndrome, as assessed by the CIWA-Ar scale, should guide the initiation of medication 4.
- Patients with a history of severe withdrawal syndrome, seizures, or delirium tremens require closer monitoring and may need more aggressive treatment 7, 6.
- The presence of underlying medical conditions, such as liver disease, should be considered when selecting medication for alcohol withdrawal syndrome 4.
- The patient's response to medication should be closely monitored, and adjustments made as needed to ensure adequate symptom control 3, 5, 6.
Medication Options
- Benzodiazepines, such as lorazepam and oxazepam, are preferred for the management of alcohol withdrawal syndrome due to their efficacy and safety profile 3, 5, 4, 6.
- Other medications, such as carbamazepine, valproic acid, and gabapentin, may be considered in certain cases, but their use is not as well established as benzodiazepines 5, 7.
- Beta blockers and clonidine may be used as adjunctive treatments to control neuroautonomic hyperactivity, but they are not effective as anticonvulsants 5, 6.