From the Guidelines
Benzodiazepines are the first-line treatment for alcohol withdrawal seizures, with lorazepam (Ativan) being the preferred agent, as recommended by the most recent and highest quality study 1. The typical dosing for lorazepam is 2-4 mg IV or IM every 15-20 minutes until seizures are controlled, not exceeding 8 mg in a 4-hour period.
Key Points:
- Lorazepam is particularly effective due to its intermediate duration of action, reliable absorption, and lack of active metabolites.
- Alternatives include diazepam (Valium) at 5-10 mg IV every 5-10 minutes as needed, or midazolam in settings where rapid action is required.
- For patients with contraindications to benzodiazepines, phenobarbital can be used at 10-20 mg/kg IV loading dose.
- After acute seizure control, patients should be maintained on a benzodiazepine taper regimen for 3-7 days to prevent recurrence.
- These medications work by enhancing GABA neurotransmission, which helps counteract the CNS hyperexcitability that occurs when alcohol is withdrawn after chronic use.
- Thiamine (100 mg IV/IM for 3-5 days, then 100 mg orally daily) should also be administered to prevent Wernicke's encephalopathy, and adequate hydration and electrolyte replacement are essential components of comprehensive management, as supported by 1 and 1.
Considerations:
- The use of benzodiazepines should be carefully monitored due to the potential risk of abuse, especially in patients with a history of substance use disorders, as noted in 1.
- Other medications, such as topiramate and baclofen, have shown promise in the treatment of alcohol withdrawal syndrome, but more research is needed to fully establish their efficacy and safety, as mentioned in 1 and 1.
From the FDA Drug Label
Diazepam is a useful adjunct in status epilepticus and severe recurrent convulsive seizures. In acute alcohol withdrawal, diazepam may be useful in the symptomatic relief of acute agitation, tremor, impending or acute delirium tremens and hallucinosis.
The best antiseizure for treatment of withdrawal seizures due to alcohol is diazepam (IV), as it is indicated for use in acute alcohol withdrawal and as an adjunct in status epilepticus and severe recurrent convulsive seizures 2.
- Key benefits: symptomatic relief of acute agitation, tremor, impending or acute delirium tremens, hallucinosis, and adjunct in status epilepticus and severe recurrent convulsive seizures.
From the Research
Treatment Options for Alcohol Withdrawal Seizures
- Benzodiazepines are commonly used to treat alcohol withdrawal seizures, with options including lorazepam, chlordiazepoxide, oxazepam, and diazepam 3, 4.
- Diazepam has been suggested as a preferred benzodiazepine for treating moderate to severe alcohol withdrawal due to its rapid onset of action and long elimination half-life, which can lead to a smoother withdrawal process 3.
- Lorazepam is also considered a first-line drug for terminating and preventing alcohol-withdrawal seizures 4.
Alternative Treatment Options
- Levetiracetam, an antiepileptic drug, has been investigated as a potential alternative to benzodiazepines for treating alcohol withdrawal syndrome, but studies have not shown significant benefits 5.
- Long-term anticonvulsant treatment is not recommended for alcohol withdrawal seizures, as it is not effective in preventing future seizures 6.
Prevention of Alcohol Withdrawal Seizures
- Oral diazepam loading has been shown to be effective in preventing alcohol withdrawal seizures in high-risk patients 7.
- Phenytoin prophylaxis is not necessary in patients at risk of alcohol withdrawal seizures, but if a patient is already taking phenytoin, it should not be abruptly discontinued in favor of diazepam loading 7.