From the Guidelines
Benzodiazepines are the primary treatment option for Alcohol Withdrawal Syndrome (AWS).
Treatment Options for AWS
The following are the treatment options for AWS:
- Benzodiazepines: considered the 'gold standard' treatment for AWS, given their efficacy for reducing both withdrawal symptoms and the risk of seizures and/or delirium tremens 1
- Long-acting benzodiazepines: (e.g. diazepam, chlordiazepoxide) provide more protection against seizures and delirium, but short and intermediate-acting benzodiazepines (e.g. lorazepam, oxazepam) are safer in elderly patients and those with hepatic dysfunction 1
- Clomethiazole: also used to treat AWS in Europe, but carries a potential risk of abuse 1
- Thiamine: should be given to all patients with AWS (100-300 mg/day) to prevent diminished cognitive function due to thiamine deficiency 1
Severity Assessment and Treatment
- Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar): useful in clinical practice to assess the severity of AWS, with a score >8 indicating moderate AWS and a score ≥15 indicating severe AWS 1
- Symptom-triggered regimen: recommended for pharmacological treatment, rather than a fixed dose schedule, to prevent the accumulation of the drug 1
Special Considerations
- Inpatient treatment: recommended for patients with serious complications of AWS, such as delirium, seizures, or physical and/or psychological comorbidities 1
- Psychoactive medication: should be dispensed in small quantities or each dose supervised to reduce the risk of misuse 1
- Benzodiazepine-sparing protocols: consisting of alpha2 agonists or anticonvulsant agents, have been proposed as alternative treatment options, but need to be evaluated in larger studies 1
From the Research
Treatment Options for Alcohol Withdrawal Syndrome (AWS)
The treatment of AWS aims to minimize symptoms, prevent complications, and facilitate continued abstinence from alcohol. The main treatment options include:
- Benzodiazepines, which are the drugs of choice in the treatment of AWS 2, 3, 4, 5, 6
- Non-benzodiazepine GABAergic medications, such as carbamazepine, gabapentin, and valproic acid, which have shown promising results in terms of safety and efficacy 2, 3, 4, 5
- Other medications, such as α2-agonists (clonidine and dexmetedomidine), β-blockers, and neuroleptic agents, which can be used as adjunctive treatments to control neuroautonomic hyperactivity and hallucinations 4, 5
- Barbiturates or propofol, which may be used in severe cases of withdrawal that require ICU admission 4
Pharmacological Treatment Approaches
Pharmacologic treatment involves the use of medications that are cross-tolerant with alcohol. Benzodiazepines may be administered on a fixed or symptom-triggered schedule 3, 5. Other medications, such as carbamazepine, oxcarbazepine, valproic acid, and gabapentin, have less abuse potential but do not prevent seizures 3.
Treatment Settings
Patients with mild or moderate AWS can be treated as outpatients, which minimizes expense and allows for less interruption of work and family life 3. Patients with severe symptoms or who are at high risk of complications should receive inpatient treatment 3, 4.