Medications for Treating Alcohol Withdrawal Symptoms

First-Line Pharmacological Treatment

Long-acting benzodiazepines, such as chlordiazepoxide and diazepam, are recommended for prevention of seizures and management of alcohol withdrawal syndrome (AWS) symptoms through GABA activation, according to the American Association for the Study of Liver Diseases 1
Standard dosing for chlordiazepoxide is 25-100 mg every 4-6 hours, as recommended by the Clinical and Molecular Hepatology guidelines 1, 4

Lorazepam, an intermediate-acting benzodiazepine, is recommended for patients with severe AWS, advanced age, recent head trauma, liver failure, respiratory failure, or other serious medical comorbidities, including obesity, as suggested by the Clinical and Molecular Hepatology guidelines 1, 4
Lorazepam is typically started at 6-12 mg/day and tapered following resolution of withdrawal symptoms, according to the Clinical and Molecular Hepatology guidelines 1
For patients with hepatic insufficiency, lorazepam is safer as it doesn't rely on hepatic oxidation, as recommended by the Praxis Medical Insights guidelines 4

Thiamine (100-300 mg/day) should be given to all AWS patients to prevent Wernicke encephalopathy, and maintained for 2-3 months following resolution of withdrawal symptoms, as recommended by the Clinical and Molecular Hepatology guidelines 1, 4
Thiamine should be administered before any glucose-containing IV fluids to prevent precipitating acute thiamine deficiency, according to the Clinical and Molecular Hepatology guidelines 1
Carbamazepine (200 mg every 6-8 hours) can be used as an alternative to benzodiazepines for seizure prevention, as suggested by the Clinical and Molecular Hepatology guidelines 1
Haloperidol (0.5-5 mg every 8-12 hours) may be used carefully as adjunctive therapy only for agitation or psychotic symptoms not controlled by benzodiazepines, according to the Clinical and Molecular Hepatology guidelines 1

Inpatient treatment is recommended for cases with serious complications, high levels of recent drinking, history of withdrawal seizures or delirium tremens, co-occurring serious medical or psychiatric illness, or failure of outpatient treatment, as recommended by the Praxis Medical Insights guidelines 4
Conservative management includes fluids, electrolytes, vitamins, and a comfortable environment, according to the Clinical and Molecular Hepatology guidelines 1
The CIWA-Ar score can guide treatment intensity—scores >8 indicate moderate AWS and scores ≥15 indicate severe AWS requiring more aggressive treatment, as suggested by the Praxis Medical Insights guidelines 4

Treatment with benzodiazepines should be tapered following resolution of withdrawal symptoms, according to the Clinical and Molecular Hepatology guidelines 1
Treatment duration should not exceed 10-14 days to avoid the risk of benzodiazepine dependence, as recommended by the Praxis Medical Insights guidelines 4

The CIWA protocol is not recommended for diagnosis of AWS as high scores may be seen in other conditions, according to the Clinical and Molecular Hepatology guidelines 1
Psychiatric consultation is recommended for evaluation, acute management of AWS, and long-term abstinence planning, as suggested by the Clinical and Molecular Hepatology guidelines 1