First-Line Treatment for 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, 3
Benzodiazepine Selection Algorithm
For Most Patients (Standard Risk)
- Diazepam 5-10 mg every 6-8 hours (oral, IV, or IM) is the preferred agent 1
- FDA labeling supports 10 mg three or four times during the first 24 hours, then reducing to 5 mg three or four times daily as needed 4
- Chlordiazepoxide 25-100 mg every 4-6 hours orally is an equally effective alternative 1, 2
- Long-acting benzodiazepines provide superior protection against seizures and delirium tremens due to their extended duration of action 1, 2
For High-Risk Patients (Switch to Short-Acting Agents)
Switch to lorazepam if the patient has ANY of the following: 1, 2, 3
- Advanced age
- Hepatic dysfunction or liver failure
- Respiratory failure
- Obesity
- Recent head trauma
Lorazepam dosing: 1-4 mg every 4-8 hours (typically 6-12 mg/day total) 1, 2, 3
- Lorazepam doesn't require hepatic oxidation, making it safer in liver impairment 2
Mandatory Adjunctive Treatment
Thiamine Administration (Critical)
- Thiamine 100-300 mg/day must be given to ALL patients with alcohol withdrawal to prevent Wernicke encephalopathy 1, 2, 3
- Always administer thiamine BEFORE any glucose-containing IV fluids to prevent precipitating acute thiamine deficiency 1, 2, 3
Additional Adjunctive Agents (When Needed)
For Seizure Prevention
- Carbamazepine 200 mg every 6-8 hours can be used as an alternative for seizure prevention 1, 2, 3
- Carbamazepine or gabapentin may be used for mild withdrawal symptoms 5
For Agitation/Psychosis Not Controlled by Benzodiazepines
- Haloperidol 0.5-5 mg every 8-12 hours may be used carefully for agitation or psychotic symptoms refractory to benzodiazepines alone 1, 2, 3
- Haloperidol is effective for hallucinations when combined with benzodiazepine therapy 6
Treatment Duration and Tapering
- Taper benzodiazepines following resolution of withdrawal symptoms 2, 3
- Total treatment duration should NOT exceed 10-14 days to avoid benzodiazepine dependence 2, 3
- Use gradual taper to discontinue diazepam or reduce dosage to minimize withdrawal reactions 4
Assessment and Monitoring
CIWA-Ar Score Guidance
- CIWA-Ar scores >8 indicate moderate AWS requiring treatment 2, 3
- Scores ≥15 indicate severe AWS requiring aggressive management 2, 3
- Do NOT use CIWA protocol alone for diagnosis, as high scores may occur in other conditions 2
Outpatient vs. Inpatient Decision
Admit for inpatient treatment if ANY of the following: 1, 2, 3
- 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: 5
- Mild to moderate withdrawal symptoms
- No additional risk factors for severe/complicated withdrawal
- Requires daily monitoring for up to 5 days after last drink 5
Critical Medications to AVOID
- Disulfiram should be avoided in severe alcoholic liver disease due to hepatotoxicity risk 1, 2, 3
- Naltrexone is not recommended in alcoholic liver disease due to hepatotoxicity risk 1, 2, 3
- Phenothiazines, barbiturates, paraldehyde, and antihistamines have no role due to toxicity or lack of efficacy 6
- Neuroleptics increase seizure risk when used alone 7
- Beta-blockers increase hallucination risk 7
Common Pitfalls
- Loading dose technique with diazepam (giving every 1-2 hours until clinical improvement/mild sedation) can simplify pharmacotherapy and prevent complications when long half-life drugs are used 6
- Phenytoin should only be given to patients with a preexisting seizure disorder, not for alcohol withdrawal seizure prevention 6
- Individual support and effective communication reduce the risk of severe withdrawal syndrome 7