What is the recommended management for alcohol withdrawal?

Management of Alcohol Withdrawal

Benzodiazepines are the gold standard first-line treatment for alcohol withdrawal syndrome, with long-acting agents (diazepam or chlordiazepoxide) preferred for most patients to prevent seizures and delirium tremens. 1, 2, 3

Initial Assessment and Risk Stratification

• Use the CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol-Revised) score to guide treatment intensity, though it should not be used alone for diagnosis as high scores can occur in other conditions 1, 2
• Scores >8 indicate moderate AWS requiring pharmacological treatment 1, 2
• Scores ≥15 indicate severe AWS requiring aggressive management 1, 2
• Assess for risk factors requiring inpatient admission: serious medical complications, high levels of recent drinking, history of withdrawal seizures or delirium tremens, co-occurring serious medical or psychiatric illness, or failure of outpatient treatment 1, 2, 3

First-Line Pharmacological Treatment

Long-Acting Benzodiazepines (Preferred for Most Patients)

Diazepam:

• Dosing: 10 mg orally 3-4 times during the first 24 hours, then reduce to 5 mg 3-4 times daily as needed 4
• Provides superior protection against seizures and delirium tremens due to longer duration of action 2, 3
• Alternative dosing range: 2-10 mg, 2-4 times daily depending on symptom severity 4

Chlordiazepoxide:

• Dosing: 25-100 mg orally every 4-6 hours 1, 3
• Equally effective alternative to diazepam for most patients 1

Intermediate-Acting Benzodiazepines (For Special Populations)

Lorazepam is the preferred agent for patients with:

• Advanced age 1, 2, 3
• Hepatic dysfunction or liver failure 1, 2, 3
• Respiratory failure 1, 2
• Obesity 1, 2, 3
• Recent head trauma 1, 2, 3

Lorazepam dosing:

• 1-4 mg every 4-8 hours (total 6-12 mg/day initially) 2, 3
• Safer in hepatic insufficiency as it doesn't rely on hepatic oxidation 1, 3
• Recent high-quality evidence shows lorazepam and diazepam are equally efficacious for severe AWS, with lorazepam being significantly more cost-effective 5

Essential Adjunctive Therapy

Thiamine (Critical - Must Not Be Omitted)

• Administer 100-300 mg/day to ALL patients with alcohol withdrawal to prevent Wernicke encephalopathy 1, 2, 3
• ALWAYS give thiamine BEFORE any glucose-containing IV fluids to prevent precipitating acute thiamine deficiency 1, 2, 3
• Continue for 2-3 months following resolution of withdrawal symptoms 1

Alternative and Adjunctive Agents

Carbamazepine:

• 200 mg every 6-8 hours as an alternative for seizure prevention 1, 2, 3
• Can be used for mild to moderate withdrawal symptoms 6

Haloperidol:

• 0.5-5 mg every 8-12 hours ONLY as adjunctive therapy for agitation or psychotic symptoms not controlled by benzodiazepines alone 1, 2, 3
• Should never be used as monotherapy 1

Treatment Duration and Tapering

• Taper benzodiazepines following resolution of withdrawal symptoms 1, 2, 3
• Total treatment duration should NOT exceed 10-14 days to avoid benzodiazepine dependence 1, 2, 3
• Use gradual taper to discontinue; if withdrawal reactions develop, pause the taper or increase dosage temporarily 4

Supportive Care

• Provide fluids and electrolyte replacement as needed based on individual losses 1
• Ensure comfortable, quiet environment 1
• Monitor daily for up to 5 days after last drink to verify symptom improvement 6

Critical Medications to AVOID

• Disulfiram should be avoided in patients with severe alcoholic liver disease due to hepatotoxicity risk 2, 3
• Naltrexone is contraindicated in patients with alcoholic liver disease due to hepatotoxicity risk 2, 3

Coordination of Care

• Obtain psychiatric consultation for comprehensive evaluation, acute AWS management, and long-term abstinence planning 1, 2
• Coordinate care between hepatologists and addiction specialists to reduce delays in referral for alcohol dependence treatment 2
• Initiate long-term treatment for alcohol use disorder, including pharmacotherapy, in addition to withdrawal management 6

Common Pitfalls

• Do not use CIWA protocol alone for diagnosis—high scores may occur in conditions other than AWS 1, 3
• Do not delay benzodiazepine therapy in patients with moderate to severe symptoms, as complications occur more frequently with delayed treatment 7
• Do not use antipsychotics, beta-blockers, or barbiturates as first-line monotherapy 8