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
Pharmacological Management Algorithm
First-Line Treatment: Benzodiazepine Selection
For most patients without contraindications:
- Long-acting benzodiazepines (diazepam or chlordiazepoxide) should be used as they provide superior protection against seizures and delirium tremens due to their extended duration of action and self-tapering pharmacokinetics 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: 25-100 mg orally every 4-6 hours 1, 3
For special populations (hepatic dysfunction, advanced age, respiratory failure, obesity, recent head trauma):
- Switch to lorazepam as it doesn't rely on hepatic oxidation, making it safer in liver impairment 1, 2, 3
- Lorazepam dosing: 1-4 mg every 4-8 hours (total 6-12 mg/day), then taper after symptom resolution 2, 3
The common concern about diazepam causing prolonged over-sedation in elderly patients or those with liver disease is unfounded and based on misunderstanding of its pharmacokinetics—clinical evidence supports its safe use with symptom-based dosing 5. The only absolute contraindication to diazepam is when intramuscular administration is the only option, as its lipophilicity results in slow absorption 5.
Essential Adjunctive Treatment
Thiamine must be administered to ALL patients with alcohol withdrawal:
- Dose: 100-300 mg/day to prevent Wernicke encephalopathy 1, 2, 3
- Critical timing: Give thiamine BEFORE any glucose-containing IV fluids to prevent precipitating acute thiamine deficiency 1, 2, 3
- Continue for 2-3 months following resolution of withdrawal symptoms 1
Alternative and Adjunctive Agents
For seizure prevention (alternative to benzodiazepines):
For agitation or psychotic symptoms not controlled by benzodiazepines alone:
- Haloperidol 0.5-5 mg every 8-12 hours may be used cautiously as adjunctive therapy only 1, 2, 3
- Pitfall: Neuroleptics increase seizure risk and should never be used as monotherapy 6
Treatment Setting Determination
Admit to inpatient treatment if ANY of the following:
- Serious medical complications present 1, 2, 3
- High levels of recent drinking 1, 3
- History of withdrawal seizures or delirium tremens 1, 2, 3
- Co-occurring serious medical or psychiatric illness 1, 2, 3
- Failure of outpatient treatment 1, 3
Outpatient treatment may be appropriate for:
- Low-risk patients without the above factors 6
- Those with adequate social support and ability to follow up 6
Monitoring and Dose Titration
Use CIWA-Ar scores to guide treatment intensity:
- Scores >8: Moderate AWS requiring treatment 1, 3
- Scores ≥15: Severe AWS requiring aggressive management 1, 2, 3
- Pitfall: Do NOT use CIWA protocol alone for diagnosis, as high scores occur in other conditions 1, 3
Conservative supportive measures include:
- Fluid and electrolyte management 1
- Comfortable, reassuring environment 1, 6
- Continuous monitoring of vital signs in severe cases 6
Treatment Duration and Tapering
Benzodiazepine tapering protocol:
- Taper following resolution of withdrawal symptoms 1, 2, 3
- Total treatment duration should NOT exceed 10-14 days to avoid benzodiazepine dependence 1, 2, 3
- If withdrawal reactions develop during taper, pause or increase to previous dose level, then decrease more slowly 4
Critical Medications to AVOID
Do NOT use in patients with alcoholic liver disease:
- Disulfiram: Risk of hepatotoxicity 2, 3
- Naltrexone: Risk of hepatotoxicity 2, 3
- Beta-blockers: Increase risk of hallucinations 6
- Clonidine: Increases risk of nightmares 6
Coordination of Care
Psychiatric consultation is recommended for:
Coordinate care between hepatologists and addiction specialists to reduce delays in referral for alcohol dependence treatment 2