From the Guidelines
Benzodiazepines are the first-line treatment for alcohol withdrawal syndrome due to their effectiveness and safety profile. According to the most recent and highest quality study 1, long-acting benzodiazepines such as chlordiazepoxide and diazepam are recommended for the prevention of seizures, with effects such as anxiety relief, sedation, and somnolence via activation of gamma-aminobutyric acid (GABA).
Key Considerations
- Diazepam (Valium) is often preferred at initial doses of 10-20mg orally every 1-4 hours as needed for symptoms, with frequency adjusted based on withdrawal severity.
- Chlordiazepoxide (Librium) is another common option, typically starting at 50-100mg orally every 6 hours.
- Lorazepam (Ativan) at 2-4mg every 1-4 hours is preferred for patients with liver impairment since it doesn't require hepatic metabolism.
- Treatment duration typically ranges from 3-7 days with gradual tapering to prevent rebound symptoms.
- Symptom-triggered dosing based on standardized assessment tools like the CIWA-Ar scale (Clinical Institute Withdrawal Assessment for Alcohol) is more effective than fixed-dose regimens.
Adjunctive Measures
- Adequate hydration is essential to prevent dehydration and electrolyte imbalances.
- Thiamine supplementation (100mg IV/IM for 3-5 days) is crucial to prevent Wernicke encephalopathy.
- Electrolyte monitoring is necessary to detect and correct any imbalances.
Special Considerations
- Patients with severe AWS, advanced age, recent head trauma, liver failure, respiratory failure, or other serious medical comorbidities may require closer monitoring and adjusted treatment regimens.
- Psychiatric consultation is recommended for the evaluation and acute management of AWS and long-term abstinence planning. As noted in 1, in patients with acute withdrawal syndrome and ALD, benzodiazepines are the treatment of choice, highlighting the importance of this treatment approach in managing alcohol withdrawal syndrome.
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
- Benzodiazepines, such as diazepam, may be useful in the management of acute alcohol withdrawal symptoms, including:
- Acute agitation
- Tremor
- Impending or acute delirium tremens
- Hallucinosis 2
From the Research
Benzodiazepines in Alcohol Withdrawal
- Benzodiazepines are considered the first-line treatment for alcohol withdrawal, as they decrease the risk of seizures and are safe to use 3.
- The most commonly used benzodiazepines for alcohol withdrawal are lorazepam, chlordiazepoxide, oxazepam, and diazepam, with no one being superior to the others 4.
- Diazepam is often preferred due to its rapid onset of action and long elimination half-life, which allows for a smoother withdrawal process 4.
- Benzodiazepines can be used in patients with liver disease and elderly patients, as long as they are administered using a simple symptom-based approach 4.
Treatment Guidelines
- The Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised, and the Short Alcohol Withdrawal Scale are commonly used tools to assess withdrawal symptoms 5.
- Patients with mild to moderate withdrawal symptoms can be treated as outpatients, while those with severe symptoms require hospitalization 5.
- Benzodiazepines are the first-line therapy for moderate to severe symptoms, with carbamazepine and gabapentin as potential adjunctive or alternative therapies 5, 6.
- Anticonvulsants, adrenergic alpha-2 agonists, betablockers, and antipsychotics can be used in combination with benzodiazepines for symptom reduction in severe alcohol withdrawal syndrome 6.
Pharmacological Treatment
- Benzodiazepines have the best evidence base for the treatment of alcohol withdrawal, followed by anticonvulsants 7.
- Symptom-monitored loading is a recommended approach for severe withdrawals, where the initial dose is guided by risk factors for complicated withdrawals and further dosing is guided by withdrawal severity 7.
- Supportive care, including the use of vitamins such as thiamine, is also an important part of the treatment plan 6, 7.