Management of Alcohol Withdrawal Syndrome
Benzodiazepines are the gold standard first-line treatment for alcohol withdrawal syndrome, with long-acting agents (diazepam or chlordiazepoxide) preferred for most patients, while lorazepam should be used for those with liver failure, advanced age, or respiratory compromise. 1, 2, 3
Pharmacological Management
First-Line Benzodiazepine Selection
For patients without hepatic dysfunction or respiratory compromise:
- Diazepam 10 mg orally 3-4 times during the first 24 hours, then reduce to 5 mg 3-4 times daily as needed 4
- Alternatively, chlordiazepoxide 25-100 mg every 4-6 hours 5, 2
- Long-acting benzodiazepines provide superior seizure and delirium tremens prevention through prolonged GABA activation 5, 3
For patients with liver failure, advanced age, recent head trauma, respiratory failure, or obesity:
- Switch to lorazepam 6-12 mg/day (typically 1-4 mg every 4-8 hours), then taper after symptom resolution 5, 1, 2
- Lorazepam is safer because it doesn't require hepatic oxidation 2
Critical Adjunctive Therapy
Thiamine 100-300 mg/day must be administered to ALL patients with alcohol withdrawal before any glucose-containing IV fluids to prevent Wernicke encephalopathy 5, 1, 2
- Continue thiamine for 2-3 months following resolution of withdrawal symptoms 5, 2
- Administering glucose before thiamine can precipitate acute Wernicke encephalopathy 1
Treatment Duration
Taper benzodiazepines following symptom resolution, with total treatment duration not exceeding 10-14 days to avoid benzodiazepine dependence 1, 2
Assessment and Monitoring
Severity Assessment
- CIWA-Ar scores >8 indicate moderate AWS requiring treatment; scores ≥15 indicate severe AWS requiring aggressive management 1, 2
- Important caveat: CIWA protocol should NOT be used for diagnosis of AWS, as high scores occur in other conditions including anxiolytic withdrawal, anxiety disorder, sepsis, hepatic encephalopathy, and severe pain 5, 2
Signs Requiring Immediate Attention
- Autonomic hyperactivity: tachycardia, hypertension, high fever, sweating 5
- Altered mental status, disorientation to person/place/time (delirium tremens typically worst at 3-5 days) 5
- Seizures (distinguish from genuine seizure disorder—alcohol withdrawal seizures don't require anticonvulsants) 5
- Comorbidities: dehydration, electrolyte imbalance, renal failure, head trauma, infection, GI bleeding, pancreatitis, liver failure 5
Treatment Setting Determination
Admit for inpatient treatment if ANY of the following are present:
- Serious complications (delirium, seizures) 5, 1
- High levels of recent drinking 1, 2
- History of withdrawal seizures or delirium tremens 1, 2
- Co-occurring serious medical or psychiatric illness 1, 2
- Failure of outpatient treatment 2
Outpatient treatment is appropriate for mild to moderate withdrawal without these risk factors 5, 6
Alternative and Adjunctive Agents
For Seizure Prevention (Alternative to Benzodiazepines)
- Carbamazepine 200 mg every 6-8 hours can be used as an alternative, particularly in outpatient settings with mild to moderate symptoms 1, 2, 7, 6
For Agitation or Psychotic Symptoms
- Haloperidol 0.5-5 mg every 8-12 hours ONLY as adjunctive therapy when benzodiazepines alone fail to control agitation or hallucinations 1, 2
- Critical warning: Neuroleptics increase seizure risk and should never replace benzodiazepines 8
Medications to AVOID
Never use disulfiram or naltrexone in patients with alcoholic liver disease due to hepatotoxicity risk 1, 3
- Beta-blockers increase hallucination risk 8
- Clonidine increases nightmare risk 8
- Phenytoin is not effective for alcohol withdrawal seizures 7
Supportive Care
- Fluids and electrolyte replacement (especially magnesium) as clinically indicated 5, 2
- Comfortable, reassuring environment with close personal support 8
- Frequent monitoring of vital signs, particularly in severe cases 5
Coordination of Care
Psychiatric consultation is recommended for comprehensive evaluation, acute AWS management, and long-term abstinence planning 5, 1, 2