What is the treatment for alcohol withdrawal seizures?

From the Guidelines

Benzodiazepines are the first-line treatment for alcohol withdrawal seizures, and intravenous lorazepam (2-4 mg) or diazepam (5-10 mg) should be administered immediately to stop seizure activity and prevent recurrence. This recommendation is based on the most recent and highest quality study available, which emphasizes the importance of benzodiazepines in managing alcohol withdrawal symptoms, including seizures and delirium tremens 1. The use of benzodiazepines has been consistently supported by various studies, including those published in 2011 1 and 2018 1, which highlight their efficacy in reducing withdrawal symptoms and preventing seizures.

Key Considerations

• Benzodiazepines work by enhancing the inhibitory effects of GABA in the brain, counteracting the hyperexcitability caused by alcohol withdrawal 1.
• After the acute seizure is controlled, a tapering regimen of benzodiazepines should be initiated, such as diazepam 10 mg every 6 hours for 24 hours, then 5 mg every 6 hours for 48 hours, with subsequent gradual reduction 1.
• Thiamine (100 mg IV or IM for 3-5 days, followed by oral supplementation) should be administered to prevent Wernicke's encephalopathy, as thiamine deficiency is common in alcohol-dependent individuals 1.
• Adequate hydration, electrolyte replacement (particularly magnesium and potassium), and close monitoring for signs of worsening withdrawal are essential 1.

Special 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 1.
• Regular monitoring is necessary to guide dosage adjustment and ensure that there is no seizure, and can be stopped after 24 hours if no specific signs appear 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION ... 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 Adjunctively in Convulsive Disorders 2 mg to 10 mg, 2 to 4 times daily

Treatment for alcohol withdrawal seizures involves the use of diazepam. The recommended dosage for symptomatic relief in acute alcohol withdrawal is 10 mg, 3 or 4 times during the first 24 hours, reducing to 5 mg, 3 or 4 times daily as needed. Additionally, diazepam can be used adjunctively in convulsive disorders at a dosage of 2 mg to 10 mg, 2 to 4 times daily 2.

• Key points:
  • Initial dose for acute alcohol withdrawal: 10 mg, 3 or 4 times during the first 24 hours
  • Reduction dose: 5 mg, 3 or 4 times daily as needed
  • Dosage for convulsive disorders: 2 mg to 10 mg, 2 to 4 times daily
• Important consideration: Gradual tapering is recommended when discontinuing or reducing the dosage of diazepam to minimize the risk of withdrawal reactions 2.

From the Research

Treatment of Alcohol Withdrawal Seizures

• Benzodiazepines are widely used to treat alcohol withdrawal seizures, as they can ameliorate or prevent the symptoms and complications of moderate to severe alcohol withdrawal, including seizures 3.
• The benzodiazepines most commonly used for this purpose are lorazepam, chlordiazepoxide, oxazepam, and diazepam, with no significant difference in efficacy between them 3, 4.
• Diazepam has been suggested as the preferred benzodiazepine for the treatment of patients experiencing moderate to severe alcohol withdrawal due to its rapid onset of action and long elimination half-life, which can result in a smoother withdrawal and lower incidence of seizures 3.
• A review of the literature suggests that benzodiazepines should still be the first-line treatment for alcohol withdrawal, as they have been shown to decrease the risk of seizures and are safe to use 5.
• Other studies have also found that benzodiazepines are effective in treating alcohol withdrawal symptoms, including seizures, and are considered the gold standard for treatment 6, 7.

Comparison of Benzodiazepines

• A study comparing lorazepam and diazepam found that both medications had similar efficacy in treating alcohol withdrawal symptoms, including seizures, and that the choice of medication should be based on individual patient needs 4.
• Another study found that benzodiazepines, in general, are effective in preventing alcohol withdrawal seizure recurrence and treating other alcohol withdrawal symptoms, but that there is no clear evidence to support the use of one benzodiazepine over another 7.

Other Treatment Options

• Other medications, such as anticonvulsants, barbiturates, and adrenergic drugs, have been used to treat alcohol withdrawal symptoms, but the evidence for their use is limited, and benzodiazepines remain the most effective treatment option 6, 7.
• Phenobarbital, with or without benzodiazepines, has been suggested as a potential treatment option for alcohol withdrawal, but more evidence is needed to determine its safety and efficacy in the emergency department setting 7.
• Phenytoin has not been shown to be effective in preventing withdrawal seizures in the emergency department setting 7.