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Treatment of Alcohol Withdrawal

Essentials

  • The patient is helped to adjust physically to function, gradually, without alcohol, and seizures, cardiac arrhytmia or delirium tremens associated with withdrawal are avoided.
  • A calm, non-judgemental environment is provided to motivate the patient to continue to deal with the problem of alcohol abuse.
  • Irreversible brain damage associated with thiamine deficiency (Wernicke encephalopathy Neurological Disorders and Alcohol) is prevented.
  • Alcohol withdrawal is always the basis for rehabiliation and further care. Mere withdrawal without rehabilitation rarely leads to successfull recovery from an alcohol problem.

Pathology

  • At least 80 g/day of pure alcohol must be consumed on a few days before clinically significant symptoms of alcohol withdrawal can occur.
  • Severe withdrawal symptoms indicate consumption of more that 180 g/day of alcohol over one or several weeks. The symptoms appear within 1-6 days (most commonly within 3-4 days).

Pharmacological treatment

  • The CIWA-Ar assessment scale should be used when considering pharmacological treatment http://www.mdcalc.com/ciwa-ar-alcohol-withdrawal.
  • Thiamine 250 mg intramuscularly (125 mg in each buttock) on three consecutive days to all patients who regularly abuse alcohol Thiamine for Wernicke-Korsakoff Syndrome in Alcohol Abuse. The absorption of the vitamin after oral administration is uncertain.
  • Mild withdrawal symptoms (a score ≤8 on the CIWA-Ar scale http://www.mdcalc.com/ciwa-ar-alcohol-withdrawal) usually do not necessitate the use of sedative medication. If the score is 9 or more, medication is needed. A score of 20 or more indicates severe withdrawal symptoms and it is likely that treatment and monitoring in a hospital is required.
  • Diazepam is effective for severe withdrawal symptoms Benzodiazepines for Alcohol Withdrawal. If the CIWA-Ar score is ≥ 19, diazepam loading is indicated. It can be used also in the treatment of moderately severe symptoms, if it is indicated based on a clinical assessment of the patient's overall state.
  • In elderly patients and in patients with liver disease, short-acting oxazepam is considered according to treatment response, usually not more than 60 mg three times daily.
  • Carbamazepine may be used in a patient with history of alcohol withdrawal seizures, but it is not a first-line withdrawal medication.
  • The dehydration and salt deficit seen in mild withdrawal symptoms is corrected orally with a sports drink or low-fat milk. In severe conditions, an infusion containing potassium and magnesium Magnesium and Alcohol Withdrawal Syndrome is necessary. NB: Do not give glucose solution in the early phase.
  • Medication for withdrawal symptoms is not ordered on prescription for home use without supervision as mixed patterns of drug use and abuse are common.
  • For withdrawal in an outpatient setting, daily medication may be given to a known patient to take along for one day at a time, e.g. chlordiazepoxideat a dose of 25-50(-75) mg 2-4 times daily Pharmacological Management of Alcohol Withdrawal.
    • Chlordiazepoxide may require special permit and local regulation applies concerning use in outpatient withdrawal.
    • Alternatively, oxazepam 15-30 mg 1-3 times daily or diazepam 5-10 mg 1-3 times daily may be used, depending on the phase of the outpatient withdrawal.
    • Medication can be tapered over a period of a few days. A known patient may fetch the medication every 1(-3) day(s) from the treatment facility, provided that he/she is sober when collecting the medication.
    • If treatment response is poor or drinking continues, the patient should be referred for institutional withdrawal.
  • Consider also local regulations regarding treatment of visitors whose place of residence is elsewhere.

Diazepam loading

Basic rule

  • The patient is given a loading dose of diazepam during the course of less than 12 hours. The elimination of the drug and its active metabolites takes several days. The treatment is carried out in an institutionalized setting.
  • Dehydration and disturbed electrolyte balance are corrected.

To observe

  • Prior to starting the medication rule out the possibility of skull injury, infection, diabetes or drug intoxication.
  • A delirium may be life-threatening if left untreated.

Dosing

  • A dose of 20 mg of diaze pam mixture Benzodiazepines for Alcohol Withdrawal is given orally every 90 to 120 minutes until the patient falls asleep peacefully. If the breath analyser measures more than 0.1 % alcohol, the starting dose is 10 mg.
  • The mean total dose of diazepam needed for loading is 80-120 mg (4-5 doses over 8-10 hours). A dose below 180 mg is sufficient in more than 90% or the patients. For a delirious patient even larger doses may be necessary. If necessary, the sedative effect of diazepam can be boostered by giving 5 mg of haloperidol orally if the patient is violent and especially if he/she has hallucinations.
  • The most common error is a too slow administration of diazepam.

Aftercare

  • The patient must be observed for at least 2 days on ward from the onset of the loading dose treatment. The initial dose of diazepam is sufficient to ensure sleep during several following nights. In case the patient suffers from sleep disturbances, 20 mg temazepam can be given on the first 5-10 evenings.
  • On leaving the ward, the patient is given (preferably written) a warning stating that the medication influences adversely the ability to perform and drive a vehicle during the following 5 days. Drinking alcohol is not recommended during this period.
  • The use of large dose antipsychotics is not recommended in alcohol withdrawal as they lower the threshold of seizures Pharmacological Management of Alcohol Withdrawal and may cause hypotension. Anticonvulsants for Alcohol Withdrawal, Psychotropic Analgesic Nitrous Oxide (Pan) for Alcoholic Withdrawal States
  • The patient is guided to a relevant point of care for the assessment and arrangement of further care within 1 to 3 weeks; this may take place, e.g., in the occupational health services, in a health centre or in a specialized clinic for the treatment of alcohol addiction Providing Care for an Alcohol or Drug Abuser.

References

  • Nimmerrichter AA, Walter H, Gutierrez-Lobos KE, Lesch OM. Double-blind controlled trial of gamma-hydroxybutyrate and clomethiazole in the treatment of alcohol withdrawal. Alcohol Alcohol 2002 Jan-Feb;37(1):67-73. [PubMed]

Evidence Summaries ⬆