What is the recommended treatment for alcohol withdrawal?

Treatment of Alcohol Withdrawal Syndrome

Benzodiazepines are the gold standard first-line treatment for alcohol withdrawal, with long-acting agents like diazepam and chlordiazepoxide preferred for most patients to prevent seizures and delirium tremens. 1, 2, 3, 4

Initial Assessment and Treatment Setting

Admit patients to inpatient treatment if they have:

• Serious complications such as withdrawal seizures or delirium tremens 1, 2, 3
• High levels of recent drinking or history of severe withdrawal 2, 3
• Co-occurring serious medical or psychiatric illness 2, 3
• Failure of outpatient treatment 2, 3

Outpatient management is appropriate for mild to moderate withdrawal without these risk factors. 5

First-Line Pharmacological Treatment

Long-Acting Benzodiazepines (Preferred for Most Patients)

Diazepam is the optimal choice due to its rapid onset and self-tapering pharmacokinetics:

• Dosing: 10 mg orally 3-4 times during the first 24 hours, then reduce to 5 mg 3-4 times daily as needed 6
• Alternative dosing: 5-10 mg every 6-8 hours 4
• Diazepam has the shortest time to peak effect for rapid symptom control and longest half-life for smoother withdrawal with fewer breakthrough symptoms 7
• The fear of over-sedation with diazepam compared to other benzodiazepines is unfounded and based on misunderstanding of its pharmacokinetics 7

Chlordiazepoxide is an alternative long-acting option:

• Dosing: 25-100 mg orally every 4-6 hours 1, 2, 4

Intermediate-Acting Benzodiazepines (For High-Risk Patients)

Switch to lorazepam for patients with:

• Advanced age 1, 2, 3
• Hepatic dysfunction or liver failure 1, 2, 3
• Respiratory failure 1, 2, 3
• Obesity 1, 2, 3
• Recent head trauma 1, 2, 3

Lorazepam dosing:

• Start at 6-12 mg/day divided into 1-4 mg every 4-8 hours 1, 2, 3
• Lorazepam is safer in hepatic insufficiency because it doesn't rely on hepatic oxidation 2
• Taper after symptom resolution 1, 2

Treatment Duration and Tapering

Total benzodiazepine treatment should not exceed 10-14 days to avoid benzodiazepine dependence. 2, 3

Taper benzodiazepines gradually following resolution of withdrawal symptoms to reduce risk of withdrawal reactions. 2, 3, 6

Essential Adjunctive Treatment

Thiamine (Mandatory for All Patients)

Administer thiamine 100-300 mg/day to all patients with alcohol withdrawal to prevent Wernicke encephalopathy:

• Give thiamine BEFORE any glucose-containing IV fluids to prevent precipitating acute thiamine deficiency 1, 2, 3
• Maintain for 2-3 months following resolution of withdrawal symptoms 1, 2
• For prevention: 100-300 mg/day for 4-12 weeks 1
• For treatment of Wernicke encephalopathy: 100-500 mg/day for 12-24 weeks 1

Alternative and Adjunctive Agents

Carbamazepine 200 mg every 6-8 hours can be used as an alternative for seizure prevention or for mild symptoms. 2, 3, 4, 5

Haloperidol 0.5-5 mg every 8-12 hours may be used cautiously as adjunctive therapy ONLY for agitation or psychotic symptoms not controlled by benzodiazepines alone. 2, 3, 4

Gabapentin can be used for mild symptoms or as adjunctive therapy. 5

Supportive Care

Provide conservative management including:

• Fluids and electrolyte replacement (especially magnesium) 1, 2
• Vitamins 1, 2
• Comfortable, quiet environment 1, 2
• Frequent monitoring of vital signs for patients with severe withdrawal 1

Critical Pitfalls to Avoid

Do NOT use the CIWA protocol for diagnosis of alcohol withdrawal syndrome - high scores may occur in other conditions such as anxiolytic withdrawal, anxiety disorder, sepsis, hepatic encephalopathy, and severe pain. 1, 2 However, CIWA-Ar scores can guide treatment intensity once AWS is diagnosed, with scores >8 indicating moderate AWS and ≥15 indicating severe AWS requiring aggressive management. 2, 3

AVOID intramuscular diazepam - its lipophilicity results in slow, erratic absorption; use lorazepam or midazolam instead if IM administration is the only option. 7

AVOID disulfiram and naltrexone in patients with alcoholic liver disease due to hepatotoxicity risk. 3, 4

The notion that diazepam should be avoided in elderly patients or those with liver disease is based on conjecture rather than evidence - clinical data shows diazepam is safe when using symptom-based dosing. 7

Coordination of Care

Obtain psychiatric consultation for comprehensive evaluation, acute AWS management, and long-term abstinence planning. 1, 3

Coordinate care between hepatologists and addiction specialists to reduce delays in referral for alcohol dependence treatment. 3

Initiate long-term treatment for alcohol use disorder, including pharmacotherapy, in addition to withdrawal management. 5