From the Guidelines
Benzodiazepines are the first-line treatment for acute alcohol withdrawal, with a symptom-triggered approach using the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale recommended for most patients. The treatment of acute alcohol withdrawal involves using benzodiazepines, such as diazepam or lorazepam, with the dosage adjusted based on the patient's symptoms and CIWA-Ar score 1.
Key Considerations
- For patients with severe withdrawal or a history of withdrawal seizures or delirium tremens, a front-loading approach with diazepam 20mg every 1-2 hours until symptoms improve may be more appropriate.
- Thiamine (100mg IV or IM for 3-5 days, then 100mg oral daily) should be administered before glucose to prevent Wernicke's encephalopathy, as thiamine deficiency is common in alcohol-dependent individuals 1.
- Adequate hydration, electrolyte replacement (particularly magnesium and potassium), and nutritional support are essential components of care.
- For patients with contraindications to benzodiazepines, alternatives include phenobarbital, carbamazepine, or gabapentin.
- Close monitoring for complications such as seizures, delirium tremens, and cardiovascular instability is crucial, with vital signs checked regularly.
Patient-Specific Considerations
- In patients with decompensated liver disease, a personalized prescription that is symptom-adapted and favors short-acting drugs, such as oxazepam or lorazepam, is recommended to avoid drug accumulation and minimize the risk of encephalopathy 1.
- The use of benzodiazepines should be limited to the initial 10-14 days of treatment to minimize the risk of abuse, and alternative treatments, such as baclofen or sodium oxybate, may be considered for patients with alcohol use disorder 1.
From the FDA Drug Label
In acute alcohol withdrawal, diazepam may be useful in the symptomatic relief of acute agitation, tremor, impending or acute delirium tremens and hallucinosis Symptomatic Relief in Acute Alcohol Withdrawal. 10 mg, 3 or 4 times during the first 24 hours, reducing to 5 mg, 3 or 4 times daily as needed
Diazepam is useful for the treatment of acute alcohol withdrawal. The recommended dosage is 10 mg, 3 or 4 times during the first 24 hours, and can be reduced to 5 mg, 3 or 4 times daily as needed 2 2.
- Key points:
- Diazepam can help relieve symptoms of acute alcohol withdrawal, such as agitation, tremor, and hallucinosis.
- The initial dosage is higher, and then reduced as needed.
- It is essential to individualize the dosage for maximum beneficial effect and to avoid adverse effects.
From the Research
Treatment of Acute Alcohol Withdrawal
- The treatment of acute alcohol withdrawal typically involves the use of benzodiazepines, which have been shown to ameliorate or prevent the symptoms and complications of moderate to severe alcohol withdrawal 3.
- Benzodiazepines such as lorazepam, chlordiazepoxide, oxazepam, and diazepam are commonly used for this purpose, with diazepam being preferred due to its rapid onset of action and long elimination half-life 3.
- Other medications such as anticonvulsants, adrenergic alpha-2 agonists, betablockers, and antipsychotics may be used in conjunction with benzodiazepines to reduce symptoms in severe alcohol withdrawal syndrome 4.
- Thiamine should be administered to all patients to prevent Wernicke-Korsakoff encephalopathy, and any electrolytic imbalances should be corrected 4.
Comparison of Benzodiazepines
- A study comparing lorazepam and diazepam for the management of alcohol withdrawal found that patients receiving lorazepam had an admission rate similar to that of those receiving diazepam 5.
- Another study found that benzodiazepines were the mainstay of treatment for acute severe alcohol withdrawal, with other agents being used to prevent complications or treat agitation/delusions 6.
Management Strategies
- Symptom-triggered regimens are favored over fixed tapering dose regimens, although monitoring through scales can be cumbersome 7.
- Assessment and management strategies for acute severe alcohol withdrawal vary considerably, with benzodiazepines being the most commonly used agents 6.
- Supportive care and the use of vitamins are essential in the management of alcohol withdrawal syndrome 7.