pharmacological treatment of alcohol withdrawal

Last reviewed 10/2020

Drugs are required to replace alcohol during withdrawal in order to prevent delirium tremens and fits:

• chlordiazepoxide
• chlordiazepoxide is the drug of choice (1). Diazepam is an alternative
• chlordiazepoxide is the preferred benzodiazepine for community-based detoxification in view of its long half-life, and also because there is less likelihood of 'diversion' into the illicit drug scene (2) - diazepam is often a drug of abuse
• the following chlordiazepoxide regime has been recommended (1) - though the dose level and length of treatment will depend on the severity of alcohol dependence and individual patient factors (e.g. weight, sex, liver function) . A regimen based on number of alcohol units taken daily is provided in the linked item
  
  

  Day 1 &2	20-30mg chlordiazepoxide QDS
  Day 3 & 4	15mg chlordiazepoxide QDS
  Day 5	10mg chlordiazepoxide QDS
  Day 6	10mg chlordiazepoxide BD
  Day 7	10mg chlordiazepoxide nocte



dispensing should be daily, or involve the support of family members to prevent any risk of misuse or overdose. Confirm abstinence by checking for alcohol on the breath, or using a saliva test or breathalyser for three to four days

if possible, see the patient daily for the first five days and again after detoxification has finished. These do not have to be long consultations but they will allow the early detection of complications and encourage the patient to continue. Usually there will be a noticeable improvement in the patient as the detoxification progresses

where there is significant liver disease, diazepam and chlordiazepoxide metabolism is impaired, and it imay be necessary to consider a benzodiazepine that is not metabolised by the liver e.g. oxazepam

another chlordiazepoxide detoxification regime over a longer period of time (and also accounts for a gradual cessation in alcohol intake) is presented in the menu of linked items below

• chlormethiazole is recommended as a second-line drug in inpatients and is not recommended for outpatient detoxification

• haloperidol is the antipsychotic drug of choice:
• haloperidol should be reserved for acute hallucinosis, it should be used cautiously and reviewed regularly
• note that antipsychotic medication may increase the risk of seizures and is essentially indicated in the treatment of delirium tremens in patients who have a history of delusions or hallucinations during alcohol withdrawal - these patients should be referred to specialist services (2)

• confirmed or imminent acute Wernicke's encephalopathy or Korsakoff's psychosis requires treatment with a multivitamin preparation

• oral thiamine plus vitamin B and C supplements
  • in cases of mild-to-moderate alcohol dependence, oral thiamine (100mg three times daily) with vitamin B complex (one tablet three times daily) and ascorbic acid (500mg once daily) should provide adequate replacement (2)
  • if a patient is malnourished, or shows evidence of self-neglect and have symptoms of peripheral neuropathy, parental vitamin supplementation with Pabrinex im (vitamins B and C) for three to five days, followed by oral vitamin supplementation, is advised (2)
  • if features of Wernicke-Korsakoff syndrome - confusion, ataxia, ophthalmoplegia, nystagmus, memory disturbance, hypotension and hypothermia - then patients require specialist treatment with Pabrinex iv for five or more days until improvement is observed (2)

• withdrawal seizures (3):
• for people with alcohol withdrawal seizures, consider offering a quick-acting benzodiazepine (such as lorazepam) to reduce the likelihood of further seizures
• do not offer phenytoin to treat alcohol withdrawal seizures

Notes:

• NICE suggest (3) offer drug treatment for the symptoms of acute alcohol withdrawal, as follows:
  • consider offering a benzodiazepine or carbamazepine
  • chlormethiazole may be offered as an alternative to a benzodiazepine or carbamazepine. However, it should be used with caution, in inpatient settings only and according to the summary of product characteristics (SPC)
  • NICE suggest (3,4)
    • drug regimens for assisted withdrawal
      • when conducting community-based assisted withdrawal programmes, use fixed-dose medication regimens
      • fixed-dose or symptom-triggered medication regimens can be used in assisted withdrawal programmes in inpatient or residential settings. If a symptom-triggered regimen is used, all staff should be competent in monitoring symptoms effectively and the unit should have sufficient resources to allow them to do so frequently and safely.
      • prescribe and administer medication for assisted withdrawal within a standard clinical protocol. The preferred medication for assisted withdrawal is a benzodiazepine (chlordiazepoxide or diazepam)
      • in a fixed-dose regimen, titrate the initial dose of medication to the severity of alcohol dependence and/or regular daily level of alcohol consumption
        • in severe alcohol dependence higher doses will be required to adequately control withdrawal and should be prescribed according to the SPC. Make sure there is adequate supervision if high doses are administered. Gradually reduce the dose of the benzodiazepine over 7-10 days to avoid alcohol withdrawal recurring
      • a symptom-triggered approach involves tailoring the drug regimen according to the severity of withdrawal and any complications
        • the service user is monitored on a regular basis and pharmacotherapy only continues as long as the service user is showing withdrawal symptoms
      • when managing alcohol withdrawal in the community, avoid giving people who misuse alcohol large quantities of medication to take home to prevent overdose or diversion . Prescribe for installment dispensing, with no more than 2 days' medication supplied at any time
      • in a community-based assisted withdrawal programme, monitor the service user every other day during assisted withdrawal. A family member or carer should preferably oversee the administration of medication. Adjust the dose if severe withdrawal symptoms or over-sedation occur
      • do not offer clomethiazole for community-based assisted withdrawal because of the risk of overdose and
      • be aware that benzodiazepine doses may need to be reduced for children and young people , older people, and people with liver impairment
        • if benzodiazepines are used for people with liver impairment, consider one requiring limited liver metabolism (for example, lorazepam); start with a reduced dose and monitor liver function carefully. Avoid using benzodiazepines for people with severe liver impairment
          
          
  • management of delirium tremens
    • in people with delirium tremens, offer oral lorazepam as first-line treatment. If symptoms persist or oral medication is declined, offer parenteral lorazepam or haloperidol

Reference:

1. Department of Health (1999). Drug Misuse and Dependence - Guidelines on Clinical Management.
2. Prescriber 2004; 15(12):16-25.
3. NICE (April 2017).Alcohol-use disorders: diagnosis and management of physical complications
4. NICE (February 2011). Alcohol-use disorders - Diagnosis, assessment and management of harmful drinking and alcohol dependence
5. http://www.websterplace.org/