Wellbutrin and Ativan in Alcohol Detox
Wellbutrin (bupropion) is contraindicated during alcohol detoxification, while Ativan (lorazepam) is an appropriate benzodiazepine choice for specific high-risk populations undergoing alcohol withdrawal. 1
Wellbutrin (Bupropion) - Contraindicated in Alcohol Detox
Bupropion is explicitly contraindicated in patients undergoing abrupt discontinuation of alcohol due to significantly increased seizure risk. 1
- The FDA label specifically lists "patients undergoing abrupt discontinuation of alcohol, benzodiazepines, barbiturates, and antiepileptic drugs" as a contraindication for bupropion use. 1
- Alcohol withdrawal itself lowers the seizure threshold, and bupropion further increases seizure risk—this combination creates an unacceptable safety profile. 1
- Do not initiate or continue bupropion during the acute alcohol withdrawal period (typically 6-24 hours to 7 days after last drink). 2, 1
Ativan (Lorazepam) - Appropriate for Select Populations
Lorazepam is the preferred benzodiazepine for alcohol withdrawal in patients with hepatic dysfunction, advanced age, or serious medical comorbidities. 2
When to Choose Lorazepam Over Long-Acting Benzodiazepines
Switch from long-acting agents (diazepam, chlordiazepoxide) to lorazepam in these specific populations: 2
- Severe hepatic failure or advanced liver disease - lorazepam undergoes direct glucuronidation without hepatic oxidation, making it safer in liver dysfunction 2
- Advanced age - shorter half-life reduces accumulation risk 2
- Recent head trauma 2
- Respiratory failure 2
- Obesity 2
- Other serious medical comorbidities 2
Lorazepam Dosing Protocol
- Initial dosing: 1-4 mg orally, IV, or IM every 4-8 hours 2
- Starting total daily dose: 6-12 mg/day, then tapered 2, 3
- Administer based on withdrawal severity using CIWA-Ar scoring (treat if score >8, severe if ≥15) 2
Standard Alcohol Withdrawal Management
First-Line Treatment for Most Patients
Long-acting benzodiazepines (diazepam 5-10 mg every 6-8 hours or chlordiazepoxide 25-100 mg every 4-6 hours) remain first-line for most patients due to superior seizure prevention and smoother self-tapering pharmacokinetics. 2, 4
Critical Adjunctive Treatment - Non-Negotiable
Administer thiamine 100-300 mg/day BEFORE any glucose-containing IV fluids to prevent Wernicke encephalopathy. 2, 3
- Glucose administration before thiamine can precipitate acute Wernicke encephalopathy. 2, 3
- Continue thiamine for 2-3 months after symptom resolution. 2, 3
Duration and Monitoring
- Benzodiazepines should not be continued beyond 10-14 days due to abuse potential. 2
- Monitor withdrawal severity with CIWA-Ar scoring until symptoms resolve. 2
- Psychiatric consultation is mandatory after stabilization for long-term abstinence planning. 2, 3
Supportive Care
- Provide fluid and electrolyte replacement, especially magnesium (commonly depleted in chronic alcohol use). 2, 3
- Ensure calm, reassuring environment. 2
- Monitor for complications: dehydration, infection, hepatic encephalopathy, gastrointestinal bleeding. 3
Common Pitfalls to Avoid
- Never use bupropion during active alcohol withdrawal or detoxification period. 1
- Never give glucose before thiamine. 2, 3
- Do not use anticonvulsants as primary treatment for alcohol withdrawal seizures - these are rebound phenomena requiring benzodiazepines, not anticonvulsants. 3
- Do not continue benzodiazepines beyond 2 weeks without clear psychiatric indication beyond withdrawal management. 2