What is the recommended treatment for alcohol withdrawal in an adult patient with a history of alcohol use disorder?

Treatment of Alcohol Withdrawal Syndrome

Benzodiazepines are the gold standard treatment for alcohol withdrawal syndrome and should be initiated immediately upon diagnosis. 1

Initial Assessment and Triage

Admit to hospital if any of the following are present:

• Significant AWS symptoms (CIWA-Ar score >8) 1
• High levels of recent drinking 1
• History of withdrawal seizures or delirium tremens 1
• Co-occurring serious medical or psychiatric illness 1
• Failure of outpatient treatment 1

Pharmacological Management

Benzodiazepine Selection

For patients with normal liver function or mild hepatic impairment:

• Use long-acting benzodiazepines (chlordiazepoxide 25-100 mg PO every 4-6 hours OR diazepam 5-10 mg PO/IV/IM every 6-8 hours) as they provide superior protection against seizures and delirium tremens 1

For patients with hepatic dysfunction, advanced age, or respiratory compromise:

• Use lorazepam 1-4 mg PO/IV/IM every 4-8 hours, as it has no active metabolites and a shorter half-life 1, 2
• Short and intermediate-acting benzodiazepines are safer in elderly patients and those with liver disease 1, 2

Critical dosing principle:

• Use symptom-triggered regimens rather than fixed-dose schedules to prevent drug accumulation 1
• Limit benzodiazepine use to 10-14 days maximum due to abuse potential 1, 2

Essential Thiamine Supplementation

Thiamine must be administered before any glucose-containing IV fluids to prevent precipitating acute Wernicke encephalopathy: 1, 2

• Prevention dose: 100-300 mg/day PO for 4-12 weeks 1, 2
• Treatment of Wernicke encephalopathy: 100-500 mg/day for 12-24 weeks 1
• High doses are necessary to compensate for poor absorption in alcohol-dependent patients 3

Supportive Care

Provide the following to all patients: 1

• Fluid and electrolyte replacement (especially magnesium) 1
• Comfortable, reassuring environment 1, 3
• Continuous monitoring for progression to severe withdrawal 3

Management of Severe Withdrawal Complications

Seizures

• Oral benzodiazepines are the best-assessed treatment for single episodes of generalized seizures during withdrawal 3
• Carbamazepine 200 mg PO every 6-8 hours can be used as an alternative for seizure prevention 1

Delirium Tremens or Severe Agitation

• Benzodiazepines are more effective than neuroleptics in preventing delirium-related mortality 3
• Haloperidol 0.5-5 mg PO every 8-12 hours or 2-5 mg IM can be used carefully as adjunctive therapy only for hallucinations or agitation not controlled by benzodiazepines 1
• Critical warning: Neuroleptics increase seizure risk and should never be used as monotherapy 3

Alternative and Adjunctive Agents

While benzodiazepines remain first-line, the following have shown promise in specific contexts:

Baclofen:

• May be considered for uncomplicated AWS, with comparable efficacy to diazepam at 30 mg/day for 10 days 4
• However, current evidence is insufficient to support baclofen as first-line treatment for AWS 5
• More useful for long-term abstinence maintenance in patients with liver disease 2, 6

Other agents with preliminary evidence:

• Gabapentin, topiramate, and sodium oxybate have been tested but lack sufficient evidence for routine AWS treatment 1, 7
• Clonidine and beta-blockers are not recommended: clonidine increases nightmares, beta-blockers increase hallucinations 3

Common Pitfalls to Avoid

Do not use the following in AWS:

• Acamprosate, naltrexone, or disulfiram—these are for relapse prevention, not acute withdrawal 3
• Excessive water-sodium intake in patients with heart disease (risk of pulmonary edema) 3
• Neuroleptics as monotherapy (increases seizure risk) 3
• Benzodiazepines beyond 10-14 days (abuse potential) 1, 2

Always give thiamine before glucose-containing fluids to prevent precipitating acute thiamine deficiency 1, 2

Psychiatric Consultation

Psychiatric consultation is recommended for evaluation, acute management, and long-term abstinence planning 1