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 (diazepam or chlordiazepoxide) preferred for most patients to prevent seizures and delirium tremens, while lorazepam should be used in patients with liver failure, advanced age, or respiratory compromise. 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
• However, do not use CIWA for diagnosis of AWS, as high scores can occur in other conditions including anxiolytic withdrawal, anxiety disorders, sepsis, hepatic encephalopathy, and severe pain 1, 3
• Evaluate for comorbidities requiring admission: dehydration, electrolyte imbalance, renal failure, head trauma, infection, gastrointestinal bleeding, pancreatitis, and liver failure 1

Determining Treatment Setting

Admit patients to inpatient treatment if they have: 1, 2

• Significant AWS with history of withdrawal seizures or delirium tremens
• High levels of recent drinking
• Co-occurring serious medical or psychiatric illness
• Failure of outpatient treatment
• Advanced liver disease or cirrhosis

Outpatient treatment is appropriate for uncomplicated mild-to-moderate AWS, as it is more cost-effective with equivalent 6-month abstinence rates compared to inpatient care 1

Pharmacological Management

Benzodiazepine Selection Algorithm

For most patients (without liver disease or respiratory compromise): 1, 4

• Diazepam 5-10 mg PO/IV/IM every 6-8 hours 1, 4, 5
• Chlordiazepoxide 25-100 mg PO every 4-6 hours 1, 4, 6
• These long-acting agents provide superior protection against seizures and delirium tremens through their extended duration of action 1, 4

For high-risk patients (advanced age, liver failure, respiratory failure, obesity, recent head trauma): 1, 2

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

Dosing Strategy: Symptom-Triggered vs Fixed-Schedule

Use symptom-triggered dosing rather than fixed-schedule dosing to prevent drug accumulation and reduce total benzodiazepine exposure 1. Research demonstrates that symptom-triggered therapy results in 37.5 mg mean oxazepam dose versus 231.4 mg with fixed-schedule (P<.001), with treatment duration of 20 hours versus 62.7 hours (P<.001), without compromising safety or comfort 7. However, this requires frequent monitoring with validated scales, which may be cumbersome in practice 8.

Essential Adjunctive Therapy

Thiamine supplementation is mandatory for all patients: 1, 2, 4

• Administer thiamine 100-300 mg/day to prevent Wernicke encephalopathy 1, 2, 4
• Critical: Give thiamine BEFORE any glucose-containing IV fluids, as glucose administration can precipitate acute thiamine deficiency 1, 2, 4
• 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 includes: 1, 9

• Fluids and electrolyte replacement (especially magnesium)
• Vitamins
• Comfortable, low-stimulation environment

Alternative and Adjunctive Agents

Carbamazepine 200 mg PO every 6-8 hours can be used as an alternative to benzodiazepines for seizure prevention, particularly in outpatient settings with mild-to-moderate withdrawal 1, 2, 4, 10

Haloperidol 0.5-5 mg PO/IM every 8-12 hours should be used carefully as adjunctive therapy ONLY for agitation or psychotic symptoms (hallucinations) not controlled by benzodiazepines alone 1, 2, 4. This is not first-line monotherapy.

Treatment Duration and Tapering

Limit benzodiazepine treatment to 10-14 days maximum to avoid the risk of benzodiazepine dependence, as both benzodiazepines and clomethiazole carry abuse potential, with patients with alcohol use disorder at particularly high risk 1, 2, 3

Taper benzodiazepines following resolution of withdrawal symptoms rather than abrupt discontinuation 1, 2

Critical Medications to AVOID

Never use naltrexone in patients with alcoholic liver disease due to risk of hepatotoxicity 1, 2, 4, 3

Avoid disulfiram in patients with severe alcoholic liver disease due to potential hepatotoxicity 1, 2, 4, 3

Coordination of Care

Obtain psychiatric consultation for: 1, 2

• Comprehensive evaluation of AWS severity
• Acute management guidance
• Long-term abstinence planning

Coordinate care between hepatologists and addiction specialists to ensure timely referral for alcohol dependence treatment following acute withdrawal management 2

Common Pitfalls to Avoid

• Do not delay benzodiazepine therapy in moderate-to-severe AWS, as complications (seizures, delirium tremens) occur primarily when treatment is delayed 11
• Do not use beta-blockers, barbiturates, or antipsychotics as first-line monotherapy—these are inferior to benzodiazepines and should only be considered as adjuncts 9, 10
• Do not rely solely on CIWA scores for diagnosis, as they lack specificity 1
• Do not use long-acting benzodiazepines in patients with cirrhosis or severe liver disease—switch to lorazepam to avoid accumulation 1, 3