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: Long-Acting Benzodiazepines
Use diazepam or chlordiazepoxide as your default choice because their longer duration of action provides superior protection against withdrawal seizures and delirium tremens compared to shorter-acting agents. 1, 2, 3
Diazepam dosing: 10 mg orally 3-4 times during the first 24 hours, then reduce to 5 mg 3-4 times daily as needed. 4 The FDA label supports this approach for symptomatic relief in acute alcohol withdrawal. 4
Chlordiazepoxide dosing: 25-100 mg every 4-6 hours orally. 2, 3
For Special Populations: Switch to Lorazepam
Switch to lorazepam (intermediate-acting) if the patient has ANY of the following:
- Advanced age 1, 2, 3
- Hepatic dysfunction or liver failure 1, 2, 3
- Respiratory failure 1, 2, 3
- Obesity 1, 2, 3
- Recent head trauma 1, 2, 3
The rationale is that lorazepam doesn't rely on hepatic oxidation for metabolism, making it safer in these populations. 2, 3
Lorazepam dosing: 1-4 mg every 4-8 hours (total 6-12 mg/day initially), then taper after symptom resolution. 1, 2, 3 A 2024 comparative study confirmed that lorazepam and diazepam are equally efficacious for severe alcohol withdrawal, with lorazepam being significantly more cost-effective. 5
Mandatory Adjunctive Treatment
Thiamine 100-300 mg/day MUST be given to ALL patients with alcohol withdrawal to prevent Wernicke encephalopathy. 1, 2, 3 This is non-negotiable regardless of which benzodiazepine you choose.
Critical timing: Always administer thiamine BEFORE any glucose-containing IV fluids to prevent precipitating acute thiamine deficiency. 1, 2, 3 Continue thiamine for 2-3 months following resolution of withdrawal symptoms. 2
Monitoring and Dosing Strategy
Use CIWA-Ar scores to guide treatment intensity:
- Scores >8 indicate moderate AWS requiring treatment 1, 2, 3
- Scores ≥15 indicate severe AWS requiring aggressive management 1, 2, 3
However, recognize that CIWA-Ar should not be used alone for diagnosis as high scores can occur in other conditions. 2, 3
Treatment duration should not exceed 10-14 days to avoid benzodiazepine dependence. 1, 2, 3 Taper benzodiazepines following resolution of withdrawal symptoms. 1, 2, 3
Alternative Agents (Second-Line)
Carbamazepine 200 mg every 6-8 hours can be used as an alternative for seizure prevention. 1, 2, 3 A 2010 Cochrane review found some evidence that carbamazepine may be more effective than benzodiazepines for certain aspects of alcohol withdrawal, though the evidence is not definitive enough to displace benzodiazepines as first-line. 6
Haloperidol 0.5-5 mg every 8-12 hours may be used carefully as adjunctive therapy ONLY for agitation or psychotic symptoms not controlled by benzodiazepines alone. 1, 2, 3 This is not a substitute for benzodiazepines.
Inpatient vs Outpatient Decision
Admit to inpatient treatment if the patient has:
- Serious medical complications 1, 2, 3
- High levels of recent drinking 1, 3
- History of withdrawal seizures or delirium tremens 1, 3
- Co-occurring serious medical or psychiatric illness 1, 2, 3
- Failure of outpatient treatment 2, 3
Mild to moderate withdrawal without these risk factors can be managed outpatient with daily monitoring for up to 5 days after the last drink. 7
Critical Medications to AVOID
Never use disulfiram or naltrexone in patients with alcoholic liver disease due to hepatotoxicity risk. 1, 3