First-Line Treatment for 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
Benzodiazepine Selection Algorithm
For Most Patients (Standard Risk)
- Diazepam 5-10 mg every 6-8 hours orally, IV, or IM is the preferred agent due to its long duration of action providing superior protection against seizures and delirium tremens 2, 3
- For acute alcohol withdrawal specifically, the FDA-approved dosing is 10 mg, 3-4 times daily during the first 24 hours, then reducing to 5 mg, 3-4 times daily as needed 4
- Chlordiazepoxide 25-100 mg every 4-6 hours orally is an acceptable alternative 1, 2
For High-Risk Patients
- Switch to lorazepam 1-4 mg every 4-8 hours (typically 6-12 mg/day) for patients with: 1, 2, 3
- Advanced age
- Hepatic dysfunction or liver failure
- Respiratory failure
- Obesity
- Recent head trauma
- Lorazepam is safer in these populations because it doesn't rely on hepatic oxidation for metabolism 1
Essential 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
- Thiamine MUST be administered BEFORE any glucose-containing IV fluids to prevent precipitating acute thiamine deficiency 1, 2, 3
Treatment Intensity Guided by CIWA-Ar Score
- CIWA-Ar scores >8 indicate moderate AWS requiring treatment 1, 3
- CIWA-Ar scores ≥15 indicate severe AWS requiring aggressive management 3
- Caveat: Do not use CIWA protocol alone for diagnosis, as high scores may occur in other conditions 1
Alternative Agents for Specific Indications
- Carbamazepine 200 mg every 6-8 hours can be used as an alternative for seizure prevention 1, 2, 3
- Haloperidol 0.5-5 mg every 8-12 hours may be used carefully for agitation or psychotic symptoms not controlled by benzodiazepines alone 1, 2, 3
Treatment Duration and Tapering
- Taper benzodiazepines following resolution of withdrawal symptoms 1, 3
- Total treatment duration should not exceed 10-14 days to avoid benzodiazepine dependence 1, 3
- Use gradual taper to discontinue; if withdrawal reactions develop, pause the taper or increase dosage temporarily 4
Inpatient vs Outpatient Decision
- Admit to inpatient treatment for: 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
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
Common Pitfalls
- Delaying benzodiazepine therapy increases risk of complications—early treatment prevents progression to severe withdrawal 5
- Forgetting to administer thiamine before dextrose can precipitate Wernicke encephalopathy 6
- Using short-acting benzodiazepines in standard-risk patients provides inferior seizure protection compared to long-acting agents 1, 2
- Extending benzodiazepine treatment beyond 2 weeks risks creating benzodiazepine dependence 1, 3