From the Guidelines
Benzodiazepines are the first-line treatment for alcohol withdrawal, with a symptom-triggered regimen recommended to prevent drug accumulation and minimize the risk of seizures and delirium tremens. The choice of benzodiazepine depends on the patient's liver function, with long-acting benzodiazepines like diazepam and chlordiazepoxide being effective for most patients, but short-acting benzodiazepines like lorazepam or oxazepam preferred in patients with liver disease 1.
Key Considerations
- For moderate to severe withdrawal, benzodiazepines should be administered as needed, with doses adjusted based on the patient's symptoms and withdrawal severity score, such as the CIWA-Ar 1.
- Patients with liver disease should be treated with caution, and short-acting benzodiazepines may be preferred to minimize the risk of drug accumulation and hepatic encephalopathy 1.
- Adjunctive treatments, such as thiamine (100mg daily), folic acid supplementation, and correction of electrolyte imbalances, particularly magnesium, should be considered to prevent Wernicke's encephalopathy and other complications 1.
Monitoring and Treatment
- Withdrawal severity should be monitored regularly using a standardized scale like the CIWA-Ar, with medication doses adjusted accordingly 1.
- Patients should be monitored for signs of seizures, delirium tremens, and other complications, and treated promptly if they occur 1.
- The use of benzodiazepines should be limited to the initial 10-14 days of treatment, and clinicians should be aware of the potential risk of abuse and dependence 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
- Diazepam (PO) is indicated for the management of symptoms associated with alcohol withdrawal, including:
- Acute agitation
- Tremor
- Impending or acute delirium tremens
- Hallucinosis Diazepam may be useful in the symptomatic relief of these symptoms 2.
From the Research
Medication for Alcohol Withdrawal
- Benzodiazepines are commonly used to treat moderate to severe alcohol withdrawal symptoms, including autonomic hyperactivity, agitation, combativeness, hallucinations, seizures, delirium, and death 3.
- The benzodiazepines most commonly used for this purpose are lorazepam, chlordiazepoxide, oxazepam, and diazepam, with diazepam having the shortest time to peak effect and the longest elimination half-lives, resulting in a smoother withdrawal 3.
- According to recent guidelines, benzodiazepines are recommended as the first-line treatment for alcohol withdrawal syndrome, with the association of anticonvulsivants, adrenergic alpha-2 agonists, betablockers, and antipsychotics recommended for symptom reduction in severe cases 4.
- For mild symptoms, carbamazepine or gabapentin can be used, while benzodiazepines are first-line therapy for moderate to severe symptoms, with carbamazepine and gabapentin as potential adjunctive or alternative therapies 5.
- In cases of delirium tremens, benzodiazepines in supramaximal doses are usually used as the drug of choice, with supportive and symptomatic treatment also being crucial 6.
- The treatment approach may involve symptom-triggered versus fixed-schedule dosing of benzodiazepines, with symptom-triggered dosing being the preferred method for most patients in withdrawal 7.