What is the treatment for alcohol withdrawal syndrome?

From the Guidelines

Alcohol withdrawal treatment should be centered on benzodiazepines as the primary medication, with a symptom-triggered regimen using chlordiazepoxide or diazepam for mild to moderate withdrawal, and a fixed-schedule regimen for severe withdrawal or those with a history of seizures or delirium tremens, as recommended by the most recent guidelines 1.

Key Considerations

• Benzodiazepines are considered the 'gold standard' treatment for alcohol withdrawal syndrome (AWS) due to their efficacy in reducing 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.
• Supportive care, including IV fluids, thiamine, folate supplementation, and correction of electrolyte imbalances, is essential in the management of AWS 1.

Treatment Approach

• For mild to moderate withdrawal, a symptom-triggered regimen using chlordiazepoxide (25-100mg) or diazepam (5-20mg) every 1-4 hours as needed is recommended, with dosing based on withdrawal severity 1.
• For severe withdrawal or those with a history of seizures or delirium tremens, a fixed-schedule regimen is preferred, typically starting with chlordiazepoxide 50-100mg every 6 hours for 24 hours, then tapering over 3-5 days 1.
• Lorazepam (1-4mg) is preferred for patients with liver disease due to its shorter half-life and lack of active metabolites 1.

Monitoring and Adjunctive Therapy

• Monitoring using the CIWA-Ar scale helps guide treatment intensity 1.
• For severe cases, adjunctive medications may include phenobarbital, dexmedetomidine, or propofol in an ICU setting [@Example@].
• Thiamine should be given before administering IV fluids containing glucose to prevent acute thiamine deficiency 1.

From the FDA Drug Label

For the relief of withdrawal symptoms of acute alcoholism, the parenteral form* is usually used initially. If the drug is administered orally, the suggested initial dose is 50 to 100 mg, to be followed by repeated doses as needed until agitation is controlled — up to 300 mg per day In acute alcohol withdrawal, diazepam may be useful in the symptomatic relief of acute agitation, tremor, impending or acute delirium tremens and hallucinosis

Alcohol Withdrawal Treatment:

• Chlordiazepoxide can be used for the relief of withdrawal symptoms of acute alcoholism, with an initial oral dose of 50 to 100 mg, followed by repeated doses as needed until agitation is controlled, up to 300 mg per day 2.
• Diazepam may be useful in the symptomatic relief of acute agitation, tremor, impending or acute delirium tremens, and hallucinosis in acute alcohol withdrawal 3.

From the Research

Treatment Options for Alcohol Withdrawal

• Benzodiazepines are considered the first-line treatment for alcohol withdrawal, as they can ameliorate or prevent symptoms and complications such as autonomic hyperactivity, agitation, combativeness, hallucinations, seizures, delirium, and death 4, 5.
• The most commonly used benzodiazepines for this purpose are lorazepam, chlordiazepoxide, oxazepam, and diazepam, with diazepam being suggested as the preferred benzodiazepine for the treatment of patients experiencing moderate to severe alcohol withdrawal under most circumstances 4.
• Symptom-triggered benzodiazepine treatment is safe, comfortable, and associated with a decrease in the quantity of medication and duration of treatment, and is considered the preferred method for most patients in withdrawal 6, 7, 8.

Administration and Monitoring

• The administration of benzodiazepines can be determined using a standardized measure of alcohol withdrawal, such as the Clinical Institute Withdrawal Assessment for Alcohol scoring system 7.
• Symptom-triggered treatment involves administering benzodiazepines in response to the development of signs of alcohol withdrawal, whereas fixed-schedule treatment involves administering benzodiazepines at regular intervals with additional doses as needed 6.
• Monitoring through scales can be cumbersome, but is essential for effective management of alcohol withdrawal syndrome 8.

Other Treatment Considerations

• Other medications, such as anticonvulsants, barbiturates, adrenergic drugs, and GABA agonists, have been tried and have evidence for use in alcohol withdrawal treatment, but benzodiazepines have the largest and best evidence base 5, 8.
• Supportive care and use of vitamins is essential in the management of alcohol withdrawal syndrome 8.