From the Guidelines
Treatment Options for Alcohol Withdrawal Syndrome (AWS)
The primary treatment for Alcohol Withdrawal Syndrome (AWS) includes benzodiazepines, such as diazepam and lorazepam, which are effective in managing symptoms of alcohol withdrawal, including anxiety, tremors, and seizures 1. These medications work by enhancing the effects of gamma-aminobutyric acid (GABA) in the brain, which is typically suppressed by chronic alcohol use.
Benzodiazepines
- Long-acting benzodiazepines (e.g., diazepam, chlordiazepoxide) provide more protection against seizures and delirium, but may not be suitable for elderly patients or those with hepatic dysfunction 1.
- Short and intermediate-acting benzodiazepines (e.g., lorazepam, oxazepam) are safer in elderly patients and those with hepatic dysfunction 1.
- Dosage and administration: The dosage and administration of benzodiazepines vary, but typical dosages include:
Other Medications
- Clonidine and beta-blockers may be used as adjunctive therapy to manage specific symptoms, such as hypertension and anxiety 1.
- Thiamine should be given to all patients with AWS to prevent Wernicke's encephalopathy 1.
- Antipsychotic medications should not be used as stand-alone medications for the management of alcohol withdrawal, but may be used as an adjunct to benzodiazepines in severe withdrawal delirium 1.
Treatment Approach
- Symptom-triggered regimen is recommended, rather than a fixed-dose schedule, to prevent the accumulation of the drug 1.
- Inpatient treatment is recommended for patients with serious complications of AWS, such as delirium, seizures, or physical and/or psychological comorbidities 1.
- Outpatient treatment may be suitable for patients with mild to moderate AWS, but requires close monitoring and follow-up 1.
From the Research
Treatment Options for Alcohol Withdrawal Syndrome (AWS)
The treatment options for AWS include:
- Benzodiazepines, which are considered the gold-standard treatment for AWS 2
- Symptom-triggered treatment with γ-aminobutyric acid receptor agonists, which is the cornerstone of therapy 3
- Anti-seizure medications, although a systematic review and meta-analysis found no evidence to support their general first-line clinical use in AWS treatment 4
- Adjunctive therapies such as:
- Dexmedetomidine, which may be used to reduce the risk of intubation and hospitalization in the intensive care unit 5
- Phenobarbital, which may be used in certain patients 6
- Gabapentin, which may be used in certain patients 6
- Barbiturates or propofol, which may be used in severe withdrawal cases 3, 2
- α2-agonists (clonidine and dexmedetomidine) and β-blockers, which can be used to control neuroautonomic hyperactivity 2
- Neuroleptic agents, which can be used to control hallucinations 2
- Other medications such as carbamazepine, valproate, sodium oxybate, baclofen, gabapentin, and topiramate, which have been investigated with promising results 2
Implementation of Treatment Protocols
Implementation of evidence-based treatment protocols and order sets for AWS can promote evidence-based practice and improve clinical outcomes 6. These protocols may include the use of screening tools for severe withdrawal risk, such as the Prediction of Alcohol Withdrawal Severity Scale, and linkage to treatment resources for alcohol use disorder (AUD) 6.
Management of Critically Ill Patients
In critically ill patients, the goals of care should include immediate management of dehydration, nutritional deficits, and electrolyte derangements; relief of withdrawal symptoms; prevention of progression of symptoms; and treatment of comorbid illnesses 3. Symptom-triggered treatment of AWS with γ-aminobutyric acid receptor agonists is the cornerstone of therapy, and benzodiazepines are often the preferred first-line agents due to their efficacy and safety profile 3.