What is the recommended management for alcohol withdrawal?

Management of Alcohol Withdrawal Syndrome

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

Initial Assessment and Risk Stratification

• Use the CIWA-Ar score to guide treatment intensity: scores >8 indicate moderate AWS requiring pharmacological treatment, and scores ≥15 indicate severe AWS requiring aggressive management 1, 2
• Important caveat: The CIWA protocol should not be used alone for diagnosis of AWS, as high scores may occur in other conditions such as anxiolytic withdrawal, anxiety disorder, sepsis, hepatic encephalopathy, and severe pain 1
• Evaluate for comorbidities including dehydration, electrolyte imbalance, renal failure, head trauma, infection, gastrointestinal bleeding, pancreatitis, and liver failure with frequent vital sign monitoring 1

Pharmacological Management Algorithm

First-Line: Benzodiazepines

For most patients without liver disease:

• Diazepam 5-10 mg PO/IV/IM every 6-8 hours 1, 3, 4
• Alternative: Chlordiazepoxide 25-100 mg PO every 4-6 hours 1, 3, 5
• Long-acting benzodiazepines provide superior protection against seizures and delirium tremens due to their self-tapering pharmacokinetics 1, 6

For high-risk patients (advanced age, hepatic dysfunction, liver failure, respiratory failure, obesity, or recent head trauma):

• Lorazepam 1-4 mg PO/IV/IM every 4-8 hours (typically 6-12 mg/day total) 1, 2, 3
• Lorazepam is safer in these populations because it undergoes direct glucuronidation without hepatic oxidation 1, 7
• Taper following resolution of withdrawal symptoms 1, 2

Dosing Strategy

• Use symptom-triggered dosing rather than fixed-schedule dosing 1, 8
• Symptom-triggered regimens reduce total benzodiazepine dose (37.5 mg vs 231.4 mg), shorten treatment duration (20 hours vs 62.7 hours), and maintain equivalent safety and comfort 8
• Limit benzodiazepine treatment to 10-14 days maximum to avoid benzodiazepine dependence 1, 2

Essential Adjunctive Treatment

Thiamine Supplementation (MANDATORY)

• Administer thiamine 100-300 mg/day to ALL patients with alcohol withdrawal 1, 2, 3
• Critical timing: Give thiamine BEFORE any glucose-containing IV fluids to prevent precipitating acute Wernicke encephalopathy 1, 2
• Continue thiamine for 2-3 months following resolution of withdrawal symptoms 1
• For established Wernicke encephalopathy: increase to 100-500 mg/day for 12-24 weeks 1

Supportive Care

• Provide fluids, electrolytes (especially magnesium), vitamins, and a comfortable environment 1

Alternative and Adjunctive Agents

Carbamazepine

• Carbamazepine 200 mg PO every 6-8 hours as an alternative to benzodiazepines for seizure prevention 1, 2, 9
• Particularly useful for outpatient treatment of mild to moderate withdrawal 9

Haloperidol

• Haloperidol 0.5-5 mg PO/IM every 8-12 hours 1, 2
• Use carefully as adjunctive therapy ONLY for agitation or psychotic symptoms (hallucinations) not controlled by benzodiazepines alone 1
• Never use as monotherapy 1

Treatment Setting Determination

Admit for inpatient treatment if ANY of the following:

• Significant AWS with CIWA-Ar score ≥15 1, 2
• High levels of recent drinking 1, 2
• History of withdrawal seizures or delirium tremens 1, 2
• Co-occurring serious medical illness 1, 2
• Co-occurring serious psychiatric illness 1, 2
• Failure of outpatient treatment 1, 2

Outpatient treatment is acceptable for:

• Mild to moderate AWS without complications 1
• No history of severe withdrawal 1
• Reliable social support and follow-up 1

Coordination of Care

• Obtain psychiatric consultation for ALL patients for comprehensive evaluation, acute AWS management, and long-term abstinence planning 1, 2
• This is an A1 level recommendation (highest strength) 1

Critical Medications to AVOID

Never use in patients with alcoholic liver disease:

• Naltrexone: Risk of hepatotoxicity 1, 2, 3
• Disulfiram: Risk of hepatotoxicity 1, 2, 3

Avoid as first-line agents:

• Barbiturates 10
• Beta-blockers (may be used as adjuncts only) 10, 9
• Antipsychotics as monotherapy 10
• Phenytoin 9

Common Pitfalls

• Do not delay benzodiazepine treatment: Complications occur primarily when therapy is delayed 11
• Do not use fixed-schedule dosing: Symptom-triggered regimens are superior 8
• Do not forget thiamine before glucose: This can precipitate Wernicke encephalopathy 1, 2
• Do not continue benzodiazepines beyond 10-14 days: Risk of creating benzodiazepine dependence 1, 2
• Do not avoid diazepam in liver disease based on half-life concerns: This fear is based on misunderstanding of pharmacokinetics; symptom-based dosing is safe 6
• Do not give diazepam intramuscularly: Lipophilicity causes slow, erratic absorption; use lorazepam or midazolam IM instead 6