What is the treatment for alcohol withdrawal?

Treatment of Alcohol Withdrawal

Benzodiazepines are the gold standard first-line treatment for alcohol withdrawal syndrome, with long-acting agents like diazepam (10 mg every 6-8 hours) or chlordiazepoxide (25-100 mg every 4-6 hours) preferred for most patients to prevent seizures and delirium tremens. 1, 2

Initial Assessment and Severity Stratification

• Use the CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol) score to guide treatment intensity 1
• CIWA-Ar score >8 indicates moderate alcohol withdrawal syndrome requiring pharmacological treatment 3, 1
• CIWA-Ar score ≥15 indicates severe alcohol withdrawal syndrome requiring aggressive management 3, 1
• Symptom-triggered regimens are preferred over fixed-dose schedules to prevent drug accumulation 3

First-Line Pharmacological Treatment

Long-Acting Benzodiazepines (Standard Patients)

For most patients without hepatic dysfunction, use long-acting benzodiazepines: 1, 2

• Diazepam: 10 mg orally, IV, or IM every 6-8 hours 2, 4
  • For acute alcohol withdrawal in the first 24 hours: 10 mg three or four times daily 4
  • After first 24 hours: reduce to 5 mg three or four times daily as needed 4
• Chlordiazepoxide: 25-100 mg orally every 4-6 hours 5, 2
• Long-acting agents provide superior protection against withdrawal seizures and delirium tremens due to their extended duration of action 2

Short/Intermediate-Acting Benzodiazepines (High-Risk Patients)

Switch to lorazepam for patients with hepatic dysfunction, advanced age, respiratory failure, obesity, or recent head trauma: 1, 5

• Lorazepam: 1-4 mg every 4-8 hours (typically 6-12 mg/day total) 1, 2
• Lorazepam is safer in hepatic insufficiency because it doesn't rely on hepatic oxidation 5
• Important caveat: While short-acting benzodiazepines are widely recommended for cirrhotic patients, this practice lacks validation from controlled trials, and all benzodiazepines are affected by hepatic insufficiency 3

Special Consideration for Cirrhotic Patients

• More than 70% of cirrhotic patients may not require pharmacological treatment for withdrawal 3
• Only prescribe benzodiazepines if withdrawal symptoms are actually present 3
• Use symptom-adapted dosing rather than routine prophylaxis 3

Essential Adjunctive Treatment

Thiamine (Vitamin B1) - MANDATORY

Administer thiamine 100-300 mg/day to ALL patients with alcohol withdrawal to prevent Wernicke encephalopathy: 1, 5

• Critical: Give thiamine BEFORE any glucose-containing IV fluids to prevent precipitating acute thiamine deficiency 1, 5
• Continue thiamine for 2-3 months following resolution of withdrawal symptoms 5
• 30-80% of alcohol-dependent patients show clinical or biological signs of thiamine deficiency 3

Alternative and Adjunctive Agents

For Seizure Prevention

• Carbamazepine 200 mg every 6-8 hours can be used as an alternative to benzodiazepines for seizure prevention 1, 5
• Phenytoin should only be given to patients with a preexisting seizure disorder, NOT for alcohol withdrawal seizures 6

For Agitation or Psychotic Symptoms

• Haloperidol 0.5-5 mg every 8-12 hours may be used as adjunctive therapy ONLY for agitation or psychotic symptoms not controlled by benzodiazepines alone 1, 5
• Never use haloperidol as monotherapy; always combine with benzodiazepines 6

Treatment Duration and Tapering

• Taper benzodiazepines following resolution of withdrawal symptoms 1, 5
• Total treatment duration should NOT exceed 10-14 days to avoid benzodiazepine dependence 3, 1, 5
• Both benzodiazepines and clomethiazole (used in Europe) carry abuse potential, particularly in patients with alcohol use disorder 3
• Use gradual tapering to reduce risk of withdrawal reactions 4

Treatment Setting Determination

Admit to inpatient treatment for: 1, 5

• Serious medical complications
• High levels of recent drinking
• History of withdrawal seizures or delirium tremens
• Co-occurring serious medical or psychiatric illness
• Failure of outpatient treatment

Outpatient treatment is appropriate for patients with mild to moderate symptoms without these risk factors 7, 8

Critical Medications to AVOID

• Disulfiram: Avoid in patients with alcoholic liver disease due to hepatotoxicity risk 1, 2
• Naltrexone: Avoid in patients with alcoholic liver disease due to hepatotoxicity risk 1, 2
• Phenothiazines, barbiturates, paraldehyde, and antihistamines have no role due to toxicity or lack of efficacy 6

Common Pitfalls to Avoid

• Do not use CIWA-Ar for diagnosis of alcohol withdrawal syndrome—high scores can occur in other conditions 5
• Do not prescribe benzodiazepines beyond 10-14 days due to dependence risk 3, 1
• Do not give glucose-containing fluids before thiamine administration 1, 5
• Do not use phenytoin for alcohol withdrawal seizures unless patient has preexisting seizure disorder 6

Coordination of Care

• Obtain psychiatric consultation for comprehensive evaluation, acute management, and long-term abstinence planning 1, 5
• Coordinate care between hepatologists and addiction specialists to reduce delays in referral for alcohol dependence treatment 1
• Treatment of alcohol withdrawal is only the first step toward full rehabilitation 6