What is the recommended dose of chlordiazepoxide (Librium) for managing alcohol withdrawal?

Chlordiazepoxide Dosing for Alcohol Withdrawal

The recommended dose of chlordiazepoxide for alcohol withdrawal is 25-100 mg orally every 4-6 hours, with the dose tapered following resolution of withdrawal symptoms. 1

Standard Dosing Protocol

• Initial dosing: Start with 25-100 mg orally every 4-6 hours based on withdrawal severity 1, 2
• Maximum daily dose: Up to 300 mg per day may be needed for severe agitation, though this is typically reserved for acute alcoholism with severe withdrawal 3
• Tapering: Reduce doses gradually after symptom control is achieved, typically over 7-14 days to avoid benzodiazepine dependence 2, 4

When to Choose Chlordiazepoxide vs. Lorazepam

Chlordiazepoxide is preferred for most patients because it is a long-acting benzodiazepine that provides superior seizure and delirium tremens prevention through its extended duration of action. 2, 4

Switch to lorazepam (1-4 mg every 4-8 hours, starting at 6-12 mg/day) for patients with: 1, 5

• Hepatic insufficiency or liver failure
• Advanced age
• Recent head trauma
• Respiratory failure
• Obesity
• Other serious medical comorbidities

Critical Caveat About Hepatic Insufficiency

Avoid chlordiazepoxide in patients with hepatic insufficiency. 6 Chlordiazepoxide itself has minimal sedative activity—its effect depends on hepatic metabolism to active metabolites. In liver disease, unmetabolized chlordiazepoxide accumulates ("dose-stacking") before conversion to its long-acting metabolite demoxepam (half-life 14-95 hours), resulting in delayed but profound and prolonged sedation that cannot be predicted or titrated safely. 6 Lorazepam is safer because it doesn't rely on hepatic oxidation and has a predictable time-to-peak effect. 1, 2

Symptom-Triggered vs. Fixed-Schedule Dosing

Symptom-triggered therapy is superior to fixed-schedule dosing when feasible, as it reduces treatment duration from 68 hours to 9 hours and total chlordiazepoxide dose from 425 mg to 100 mg, without increasing complications. 7

• Use CIWA-Ar scores to guide dosing: scores >8 indicate moderate withdrawal requiring treatment, scores ≥15 indicate severe withdrawal requiring aggressive management 2, 5
• Administer chlordiazepoxide only when withdrawal symptoms develop, using validated assessment tools 7
• Fixed-schedule dosing (25-100 mg every 4-6 hours) remains appropriate when close monitoring is not available 1

Essential Adjunctive Treatment

Thiamine 100-300 mg/day must be given to all patients to prevent Wernicke encephalopathy, and should be administered before any glucose-containing IV fluids to avoid precipitating acute thiamine deficiency. 1, 2, 5 Continue thiamine for 2-3 months after withdrawal resolution. 1

Alternative and Adjunctive Agents

• Carbamazepine 200 mg every 6-8 hours can substitute for benzodiazepines for seizure prevention 1, 2
• Haloperidol 0.5-5 mg every 8-12 hours may be added cautiously for agitation or hallucinations not controlled by benzodiazepines alone 1, 2

Indications for Inpatient Treatment

Admit patients with: 1, 2, 5

• Significant withdrawal symptoms or CIWA-Ar ≥15
• High levels of recent drinking
• History of withdrawal seizures or delirium tremens
• Co-occurring serious medical or psychiatric illness
• Failure of outpatient treatment

Common Pitfalls

• Do not use CIWA-Ar for diagnosis of alcohol withdrawal syndrome—high scores occur in other conditions; use it only to guide treatment intensity once AWS is diagnosed 2, 4
• Do not exceed 10-14 days of benzodiazepine treatment to avoid iatrogenic dependence 2, 4
• Do not use chlordiazepoxide in liver disease—the delayed onset and unpredictable dose-stacking creates unacceptable risk of prolonged sedation 6
• Avoid naltrexone and disulfiram in patients with alcoholic liver disease due to hepatotoxicity risk 5, 4