Librium (Chlordiazepoxide) Protocol for Alcohol Withdrawal
Administer chlordiazepoxide 25-100 mg orally every 4-6 hours for alcohol withdrawal syndrome, with doses tapered over time as symptoms resolve, while ensuring all patients receive thiamine 100-300 mg/day to prevent Wernicke encephalopathy. 1
Dosing Regimen
Standard Protocol:
- Initial dose: 25-100 mg orally every 4-6 hours 1
- Taper schedule: Gradually reduce doses following resolution of withdrawal symptoms using a fixed-dose regimen with dose tapers over time 1
- Duration: Limit benzodiazepine treatment to 10-14 days maximum to avoid dependence 2
Critical Adjunctive Therapy
Thiamine administration is mandatory:
- Dose: 100-300 mg/day for all patients with alcohol withdrawal 1
- Duration: Maintain for 2-3 months following resolution of withdrawal symptoms 1
- Timing: Administer thiamine BEFORE giving any glucose-containing IV fluids, as glucose can precipitate acute thiamine deficiency 1, 2
Indications for Admission
Hospitalize patients with: 1
- History of withdrawal seizures or delirium tremens
- Significant AWS with high levels of recent drinking
- Serious medical or psychiatric comorbidities
- Failed outpatient treatment
When NOT to Use Chlordiazepoxide
Switch to lorazepam (1-4 mg every 4-8 hours) for patients with: 1
- Liver failure or hepatic insufficiency
- Advanced age
- Recent head trauma
- Respiratory failure
- Obesity
- Other serious medical comorbidities
Critical caveat: Chlordiazepoxide undergoes hepatic oxidation and has minimal sedative activity itself—its effect depends primarily on active metabolites (particularly demoxepam with half-life 14-95 hours). 3 In hepatic insufficiency, delayed metabolism causes "dose-stacking" where unmetabolized drug accumulates, then slowly converts to long-acting metabolites, resulting in delayed but profound and prolonged sedation even after dosing stops. 3 This makes chlordiazepoxide particularly problematic in liver disease despite being a traditional choice for alcohol withdrawal.
Supportive Management
General measures include: 1
- Fluid and electrolyte replacement (especially magnesium)
- Vitamins
- Comfortable, quiet environment
Monitoring Requirements
- Assess withdrawal severity regularly, though CIWA is helpful for treatment planning but NOT recommended for diagnosis of AWS 1
- Monitor vital signs and withdrawal symptoms closely, especially in first 72 hours 4
- Psychiatric consultation is recommended for evaluation, acute management, and long-term abstinence planning 1
Adjunctive Medications When Needed
For agitation or hallucinations not controlled by benzodiazepines:
- Haloperidol 0.5-5 mg orally every 8-12 hours or 2-5 mg IM 1
- Use carefully as adjunctive therapy only 1
Alternative for seizure prevention:
- Carbamazepine 200 mg orally every 6-8 hours 1
Comparative Efficacy
Chlordiazepoxide and lorazepam show similar efficacy in reducing alcohol withdrawal symptoms. 5, 6 However, patients treated with chlordiazepoxide may require more adjuvant "as needed" benzodiazepine therapy to control breakthrough symptoms compared to those receiving lorazepam. 6