From the Guidelines
Management of Inpatient Alcohol Withdrawal Syndrome (AWS) Complicated by Seizure
The management of inpatient AWS complicated by seizure should primarily involve the use of benzodiazepines as the first-line treatment to reduce withdrawal symptoms and prevent further seizures and delirium tremens 1.
Key Considerations
- Benzodiazepine Choice: Long-acting benzodiazepines (e.g., diazepam, chlordiazepoxide) are preferred for their protective effects against seizures and delirium, but short and intermediate-acting benzodiazepines (e.g., lorazepam, oxazepam) are safer in patients with hepatic dysfunction or elderly patients 1.
- Dosing and Monitoring: A symptom-triggered regimen rather than a fixed dose schedule is recommended to prevent drug accumulation and to tailor the treatment to the individual patient's needs 1. Regular monitoring is crucial to guide dosage adjustment and prevent seizures 1.
- Thiamine Supplementation: Thiamine (100-300 mg/day) should be given to all patients with AWS to prevent Wernicke's encephalopathy, considering the high prevalence of thiamine deficiency in alcohol-dependent individuals 1.
- Psychiatric Consultation and Inpatient Treatment: Given the complexity and potential severity of AWS complicated by seizure, psychiatric consultation is recommended for evaluation, treatment, and long-term planning of alcohol abstinence, and inpatient treatment is necessary for cases with serious complications such as seizures 1.
Treatment Approach
- Assessment: Use the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) to assess the severity of AWS, though recognizing its limitations in certain conditions 1.
- Benzodiazepine Administration: Initiate with a suitable benzodiazepine based on patient factors (e.g., lorazepam 6-12 mg/day for severe AWS or in patients with advanced age, liver failure, etc.) and adjust as necessary 1.
- Supportive Care: Ensure adequate hydration, electrolyte balance, and monitor for potential complications such as delirium tremens, seizures, and other medical comorbidities.
- Long-term Planning: Include strategies for maintaining abstinence and addressing alcohol use disorder, potentially involving medications like topiramate and baclofen, which have shown promise in treating AWS and preventing relapse 1.
From the Research
Management of Inpatient Alcohol Withdrawal Syndrome (AWS) Complicated by Seizure
- The management of AWS complicated by seizure requires a coordinated, multidisciplinary approach, as patients with AWS often have multiple management issues, including withdrawal symptoms, delirium tremens, seizures, and electrolyte disturbances 2.
- Benzodiazepines are the recommended treatment for inpatient management of AWS, including cases complicated by seizure, as they have been shown to be effective in reducing the risk of seizures and delirium tremens 3.
- Anti-seizure medications (ASMs) have been used historically as treatment options in AWS, but a systematic review and meta-analysis found no evidence to support their general first-line clinical use in AWS treatment, including cases complicated by seizure 4.
- Phenobarbital has been suggested as a safe alternative treatment for AWS on general medical wards, including cases complicated by seizure, with a low rate of serious adverse events and treatment failures 5.
- The treatment of alcohol dependence is more important and should be prioritized before the prevention of further seizures, as withdrawal seizures do not recur if the patient remains abstinent, and long-term administration of antiepileptic drugs is unnecessary in abstinent patients 3.
- In the emergency department, symptom-triggered benzodiazepine administration remains the most commonly provided treatment for AWS, but alternative regimens, such as short courses of barbiturates or novel anticonvulsants, may be considered for patients with significant medical or psychiatric comorbidity or pending discharge 6.