Alcohol Withdrawal Management
First-Line Treatment
Benzodiazepines are the gold standard first-line treatment for alcohol withdrawal, with long-acting agents (diazepam or chlordiazepoxide) preferred for most patients due to superior protection against seizures and delirium tremens. 1, 2
Benzodiazepine Selection Algorithm
For Most Patients (Standard Choice)
- Long-acting benzodiazepines (diazepam or chlordiazepoxide) provide the best protection against seizures and delirium tremens 1, 2, 3
- Diazepam dosing: 10 mg orally 3-4 times during the first 24 hours, then reduce to 5 mg 3-4 times daily as needed 4
- Chlordiazepoxide dosing: 50-100 mg orally initially, then 25-100 mg every 4-6 hours as needed (maximum 300 mg in first 24 hours) 3
For High-Risk Patients (Modified Approach)
Switch to short or intermediate-acting benzodiazepines (lorazepam or oxazepam) in patients with: 1, 2, 3
- Hepatic dysfunction or advanced liver disease
- Elderly age
- Respiratory failure
- Obesity (use lorazepam 6-12 mg/day instead of chlordiazepoxide) 3
Dosing Strategies
Symptom-Triggered Therapy (Preferred When Feasible)
- Use CIWA-Ar scale to guide dosing: scores >8 indicate moderate withdrawal, ≥15 indicate severe withdrawal requiring aggressive treatment 2
- Administer benzodiazepines based on symptom severity rather than fixed schedule 5, 6
- This approach reduces total medication dose and treatment duration 7
Front-Loading Approach
- Give 20 mg diazepam orally every 1-2 hours until symptoms controlled 8
- Takes advantage of diazepam's long half-life for kinetic tapering 8
- Median of 3 doses (range 1-12) given over 7.6 hours effectively treats most patients 8
Fixed-Schedule Tapering
- Alternative for patients who cannot be monitored with symptom scales 9, 7
- Taper over several days with predetermined doses 7
Critical Adjunctive Treatment
Thiamine Administration (Mandatory)
- Administer thiamine 100-300 mg/day to ALL patients with alcohol withdrawal 2, 3
- Give thiamine BEFORE any glucose-containing IV fluids to prevent precipitating Wernicke encephalopathy 3, 5
- Use parenteral thiamine for malnourished patients, severe withdrawal, or suspected Wernicke's encephalopathy 2
Treatment Duration and Discontinuation
- Limit benzodiazepine treatment to 7-10 days maximum to avoid dependence 2, 5
- Use gradual taper when discontinuing to reduce withdrawal reactions 4
- If withdrawal reactions develop during taper, pause or increase to previous dose level, then decrease more slowly 4
Management of Complications
Seizures
- Benzodiazepines remain the treatment of choice for alcohol withdrawal seizures, NOT anticonvulsants 2, 3
- Do not use anticonvulsants as monotherapy 3
Severe Withdrawal/Delirium Tremens
- Benzodiazepines are more effective than neuroleptics in preventing delirium-related mortality 5
- May require ICU admission with barbiturates or propofol for refractory cases 9
Alternative Agents (When Benzodiazepines Contraindicated)
- Carbamazepine 200 mg every 6-8 hours is effective for seizure prevention when benzodiazepines cannot be used 1, 3
- Baclofen and topiramate show promise for both withdrawal management and relapse prevention, though evidence remains preliminary 1, 3, 9
Agents to Avoid
- Do NOT use antipsychotics as stand-alone treatment for alcohol withdrawal 2
- Do NOT substitute gabapentin for benzodiazepines in moderate to severe withdrawal—this increases risk of seizures and delirium tremens 3
- Beta-blockers increase hallucination risk; clonidine increases nightmare risk 5
- Neuroleptics increase seizure risk 5
Treatment Setting Considerations
Inpatient management is preferred for patients with: 2
- Risk of severe withdrawal
- Concurrent serious physical or psychiatric disorders
- Lack of adequate social support
- History of delirium tremens or withdrawal seizures 5
Post-Withdrawal Relapse Prevention
After acute withdrawal is managed, consider medications to prevent relapse: 2