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
Benzodiazepine Selection Algorithm
For Most Patients (Standard Choice)
- Long-acting benzodiazepines provide superior protection against seizures and delirium tremens due to their self-tapering pharmacokinetic profile 3, 2
- Diazepam 5-10 mg every 6-8 hours (oral, IV, or IM) is the preferred agent given its rapid onset and longest elimination half-life, which creates a smoother withdrawal with fewer breakthrough symptoms 2, 4, 5
- Chlordiazepoxide 25-100 mg every 4-6 hours orally is an equally effective alternative 2, 6, 7
For High-Risk Patients (Switch to Short/Intermediate-Acting)
Switch to lorazepam for patients with: 1, 2, 6
- Advanced age (elderly patients)
- Hepatic dysfunction or liver failure
- Respiratory failure
- Obesity
- Recent head trauma
Lorazepam dosing: 1-4 mg every 4-8 hours (typically 6-12 mg/day total), then taper after symptom resolution 1, 2, 6
The rationale is that lorazepam undergoes direct glucuronidation rather than hepatic oxidation, making it safer in hepatic impairment 6. The widespread belief that diazepam causes excessive sedation in liver disease is actually unfounded and based on pharmacokinetic misunderstanding 5.
Dosing Strategy: Symptom-Triggered vs Fixed-Schedule
Symptom-triggered dosing using CIWA-Ar scores reduces total benzodiazepine exposure and treatment duration without compromising safety 8
- Treat when CIWA-Ar score >8 (moderate withdrawal)
- Aggressive management when CIWA-Ar score ≥15 (severe withdrawal) 1
- This approach decreased mean oxazepam dose from 231.4 mg to 37.5 mg and treatment duration from 62.7 to 20.0 hours compared to fixed-schedule dosing 8
Loading dose technique for severe cases: Give diazepam every 1-2 hours until clinical improvement or mild sedation is achieved, then no further therapy is typically needed due to the long half-life 9
Essential Adjunctive Treatment
Thiamine 100-300 mg/day must be administered to ALL patients with alcohol withdrawal to prevent Wernicke encephalopathy 1, 2, 6
- Administer thiamine BEFORE any glucose-containing IV fluids to prevent precipitating acute thiamine deficiency 1, 2, 6
- Continue for 2-3 months following resolution of withdrawal symptoms 6
Alternative Agents for Specific Situations
Carbamazepine 200 mg 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, 10
Haloperidol 0.5-5 mg every 8-12 hours may be added as adjunctive therapy ONLY for agitation or psychotic symptoms not controlled by benzodiazepines alone 1, 2, 6
Treatment Duration and Tapering
Taper benzodiazepines following resolution of withdrawal symptoms, with total treatment duration not exceeding 10-14 days to avoid benzodiazepine dependence 1, 6
Inpatient vs Outpatient Decision
Admit to inpatient treatment for: 1, 2, 6
- 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
Most patients with mild withdrawal can be managed safely as outpatients with supportive care 9, 10
Critical Medications to AVOID
Never use disulfiram or naltrexone in patients with alcoholic liver disease due to significant hepatotoxicity risk 3, 1, 2
Avoid phenothiazines, barbiturates (except for severe ICU cases), paraldehyde, and antihistamines due to toxicity or lack of efficacy 9
Phenytoin should only be given to patients with pre-existing seizure disorders, as it does not prevent alcohol withdrawal seizures 9
Common Pitfalls
- Do not use CIWA-Ar for diagnosis of AWS, only for guiding treatment intensity, as high scores occur in other conditions 6
- The intramuscular route should be avoided for diazepam due to erratic absorption from its lipophilicity; use lorazepam or midazolam IM instead 5
- Early treatment initiation prevents progression to severe complications—do not wait for symptoms to worsen 9