What medications are used to manage alcohol withdrawal?

Medication Management for Alcohol Withdrawal

Benzodiazepines are the gold standard first-line treatment for alcohol withdrawal syndrome, with long-acting agents like diazepam and chlordiazepoxide preferred for most patients due to superior seizure and delirium tremens prevention. 1, 2

Primary Pharmacological Treatment

Long-Acting Benzodiazepines (First-Line for Most Patients)

Long-acting benzodiazepines should be your default choice because their extended duration of action provides better protection against seizures and delirium tremens through self-tapering pharmacokinetics. 1, 2

• Diazepam: 5-10 mg every 6-8 hours (oral, IV, or IM) 3, 2

  • Has the shortest time to peak effect, allowing rapid symptom control and accurate titration 4
  • The long elimination half-life creates a gradual, self-tapering effect that reduces breakthrough symptoms and rebound phenomena 4
  • FDA-approved for symptomatic relief of acute agitation, tremor, impending or acute delirium tremens, and hallucinosis in acute alcohol withdrawal 5

• Chlordiazepoxide: 25-100 mg every 4-6 hours (oral) 3, 1

  • Alternative long-acting option with similar efficacy profile 1

Intermediate-Acting Benzodiazepines (For High-Risk Patients)

Switch to lorazepam for patients with hepatic dysfunction, advanced age, respiratory failure, obesity, or recent head trauma. 1, 2

• Lorazepam: 1-4 mg every 4-8 hours, typically starting at 6-12 mg/day 3, 1
  • Does not rely on hepatic oxidation, making it safer in liver impairment 1, 6
  • Preferred in severe AWS and patients with serious medical comorbidities 3, 1
  • Taper following resolution of withdrawal symptoms 3

Critical caveat: The common fear of over-sedation with diazepam compared to other benzodiazepines is unfounded and based on misunderstanding of pharmacokinetics—diazepam is safe even in elderly patients and those with liver disease when using symptom-based dosing. 4 However, avoid intramuscular diazepam due to slow absorption from lipophilicity; use lorazepam or midazolam IM instead. 4

Essential Adjunctive Medications

Thiamine (Mandatory for All Patients)

Give thiamine 100-300 mg/day to every patient with alcohol withdrawal to prevent Wernicke encephalopathy. 3, 1, 2

• Maintain for 2-3 months following resolution of withdrawal symptoms 3, 1
• Always administer thiamine BEFORE any glucose-containing IV fluids to prevent precipitating acute thiamine deficiency 3, 1, 6
• For established Wernicke encephalopathy: increase to 100-500 mg/day for 12-24 weeks 3

Alternative and Adjunctive Agents

• Carbamazepine: 200 mg every 6-8 hours as an alternative to benzodiazepines for seizure prevention 3, 1, 2

  • Useful when benzodiazepines are contraindicated, though less evidence than benzodiazepines 7

• Haloperidol: 0.5-5 mg every 8-12 hours (oral or IM) 3, 1, 2

  • Use carefully and only as adjunctive therapy for agitation or psychotic symptoms (hallucinations) not controlled by benzodiazepines 3, 1
  • Caution: Neuroleptics increase seizure risk 8

Treatment Setting Determination

Admit to inpatient treatment if the patient has: 3, 1, 2

• Significant AWS with delirium, seizures, or delirium tremens
• High levels of recent drinking
• History of withdrawal seizures or delirium tremens
• Co-occurring serious medical or psychiatric illness
• Failure of outpatient treatment
• Physical and/or psychological comorbidities requiring monitoring 3

Outpatient management may be appropriate for low-risk patients without these complications. 8

Monitoring and Treatment Duration

• CIWA-Ar scores guide treatment intensity: scores >8 indicate moderate AWS; scores ≥15 indicate severe AWS requiring aggressive treatment 1, 6

  • Important pitfall: Do not use CIWA protocol alone for diagnosis, as high scores occur in other conditions 1, 6

• Limit benzodiazepine treatment to 10-14 days maximum to avoid benzodiazepine dependence 1, 6

• Taper benzodiazepines following resolution of withdrawal symptoms 3, 6

Supportive Care

Provide fluids, electrolytes (especially magnesium), vitamins, and a comfortable environment. 3 Avoid excessive water-sodium intake in patients with heart disease due to pulmonary edema risk. 8

Medications to Avoid in Alcohol Withdrawal

• Disulfiram and naltrexone: Contraindicated in severe alcoholic liver disease due to hepatotoxicity 2, 6
• Beta-blockers: Increase hallucination risk 8
• Clonidine: Increases nightmare risk 8
• Acamprosate, naltrexone, disulfiram: Not beneficial in acute withdrawal 8

Psychiatric Consultation

Request psychiatric consultation for all AWS patients for evaluation, acute management, and long-term abstinence planning. 3, 1