Drug of Choice for Alcohol Withdrawal
Benzodiazepines are the drug of choice for managing alcohol withdrawal, with long-acting agents like diazepam and chlordiazepoxide preferred for most patients due to superior seizure prevention and smoother withdrawal through self-tapering pharmacokinetics. 1, 2, 3
Primary Pharmacological Treatment
First-Line: Long-Acting Benzodiazepines
Diazepam is the preferred benzodiazepine for most patients with moderate to severe alcohol withdrawal due to its rapid onset (shortest time to peak effect) and long elimination half-life, which provides gradual self-tapering and superior protection against seizures and delirium tremens 2, 4
Standard diazepam dosing: 5-10 mg orally, IV, or IM every 6-8 hours, with doses tapered over time 1, 2
Chlordiazepoxide is an equally effective alternative: 25-100 mg orally every 4-6 hours 1
The long half-lives of these agents result in smoother withdrawal with lower incidence of breakthrough symptoms and rebound phenomena, including decreased seizure risk 4
When to Use Lorazepam Instead
Switch to lorazepam (intermediate-acting benzodiazepine) in specific high-risk populations where hepatic metabolism is compromised or accumulation is dangerous 1:
Advanced age (elderly patients) 1
Recent head trauma 1
Respiratory failure 1
Obesity 1
Other serious medical comorbidities 1
Lorazepam dosing: 1-4 mg orally, IV, or IM every 4-8 hours, starting at 6-12 mg/day total, then tapered 1
Critical Adjunctive Treatment
Thiamine Supplementation (Mandatory)
All patients with alcohol withdrawal must receive thiamine 100-300 mg/day to prevent Wernicke encephalopathy, maintained for 2-3 months (or 4-12 weeks for prevention) after symptom resolution 1, 2, 5
Thiamine must be administered BEFORE any glucose-containing IV fluids, as glucose administration can precipitate acute thiamine deficiency and Wernicke encephalopathy 1, 2, 5
For established Wernicke encephalopathy: increase to 100-500 mg/day for 12-24 weeks 1
Treatment Duration and Safety
Benzodiazepines should not be continued beyond 10-14 days due to abuse potential, especially critical in patients with alcohol use disorder 2, 5
Treatment should use symptom-triggered or fixed-dose regimens with dose tapers over time 1, 2
Alternative Agents (Limited Role)
Carbamazepine (200 mg every 6-8 hours) can be used as an alternative to benzodiazepines for seizure prevention, though benzodiazepines remain superior 1, 6
Haloperidol (0.5-5 mg every 8-12 hours orally; 2-5 mg IM) should only be used carefully as adjunctive therapy for agitation or psychotic symptoms (hallucinations) not controlled by benzodiazepines alone 1
Other agents like beta-blockers, clonidine, and neuroleptics have inferior efficacy profiles or increase complication risks (neuroleptics increase seizure risk) 6
Indications for Inpatient Treatment
Admit patients with any of the following high-risk features 1:
- Significant alcohol withdrawal syndrome severity
- History of withdrawal seizures or delirium tremens
- High levels of recent drinking
- Co-occurring serious medical or psychiatric illness
- Failure of outpatient treatment 1
Route of Administration Caveat
Avoid intramuscular diazepam due to its lipophilicity causing slow and erratic absorption; use lorazepam IM or midazolam IM when rapid symptom control is needed and oral/IV routes are unavailable 4