Therapeutics and Drug Brief

Pharmacological Management of Alcohol Withdrawal

Source: Mayo-Smith M. JAMA 1997;278:144-151.

Alcohol withdrawal (ad) and its management represent a major public health problem. There remains some uncertainty about optimum pharmacotherapeutic management of withdrawal, especially its efficacy in reducing consequences such as seizures or delirium. There is substantial diversity in therapeutic approaches by even expert clinicians, as well as literature sources. This review provides a practice guideline that evolved as a result of meta-analysis including 134 articles, and the commentary below summarizes some of the prominent conclusions.

Benzodiazepines are effective in reducing signs and symptoms of AD, including a risk reduction of 7.7 seizures/100 patients treated and 4.9 cases of delirium/100 patients treated. They are the recommended agent by the guideline. All benzodiazepines are similarly efficacious, though longer-acting agents have associated benefits of overall smoother withdrawal with less breakthrough or rebound. On the other hand, especially in the elderly or those with hepatic impairment, longer-acting agents may produce excess sedation.

Structured assessment scales are suggested in substance abuse treatment programs, for initial assessment and monitoring of progress, and to help in drug dose titration. Medication is recommended to include patients 1) with moderate-severe symptoms, 2) with previous history of withdrawal symptoms, and 3) with some comorbid conditions. In settings without specific training for symptom-triggered therapy, fixed-schedule therapy is recommended, with options for individualization of therapy and adding medication for uncontrolled symptoms.

Beta-blockers, clonidine, carbamazepine, and neuroleptics are not recommended as monotherapy for AD.