Diazepam, lorazepam (Ativan), and chlordiazepoxide (Librium) are the most common benzos used.

Symptom-triggered therapy (Give medication only when the patient has symptoms)
If CIWA-Ar ≥ 8, treat with benzos.
Lorazepam 2-4 mg, IV Push, Q4hrs PRN for CIWA score greater than 10. Notify MD if two consecutive CIWA scores greater than 10

Pearls / Other medications for acute withdrawal

  • Diazepam 5 to 10 mg IV, repeated every 5 to 10 minutes until appropriate sedation is achieved.
  • Lorazepam 2 to 4 mg IV, repeated every 15 to 20 minutes until appropriate sedation is achieved, is another alternative.
  • Appropriate Sedation: The general goal of sedation is a calm but alert state.
  • When appropriate sedation is achieved, then titrate benzos to CIWA-Ar score.
  • Evaluation intervals: Do a CIWA-Ar q15 min for severe symptoms. Then space it out to q1h and q4h as symptoms improve.
  • Evaluate q1h until CIWA-Ar score <8 for 8 hours. Then q2h for another 8 hours. And if stable, then q4h.
  • Diazepam 5 to 10 mg IV (or chlordiazepoxide 25 to 100 mg orally) for any score of 8 or greater on the CIWA-Ar.
  • Use IV benzos until the patient is no longer delirious, is not at high risk for aspiration, and that absorption from the gut is reliable.
  • If refractory to aggressive treatment with high-dose PRN benzos, transfer to the ICU and treat with benzo drip, phenobarbital, or propofol.
  • Symptom-triggered therapy is superior to fixed schedule therapy.
  • Avoid haloperidol (it decreases seizure threshold).
  • Avoid beta-blockers and central acting alpha-2 agonists because they mask symptoms.
  • Use RASS instead of CIWA-Ar in patients who cannot answer questions, such as those who are intubated in the ICU.
  • Taper the dose of benzodiazepines before stopping.
  •  Benzos do two key things in alcohol withdrawal: 1) treat the psychomotor agitation, 2) prevent progression from minor to major withdrawal symptoms.

Choosing the appropriate benzodiazepine

Diazepam or Chlordiazepoxide are preferred as 1st-line: “In general, Long-acting benzodiazepines with active metabolites (eg, diazepam or chlordiazepoxide) are preferred because they seem to result in a smoother course with less chance of recurrent withdrawal or seizures.”

Lorazepam or Oxazepam are preferred in advanced cirrhosis or acute alcoholic hepatitis: The shorter half-life of lorazepam and the absence of active metabolites with oxazepam may prevent prolonged effects if oversedation occurs.

Avoid chlordiazepoxide in patients with severe liver disease. It’s long half-life and may lead to oversedation.

Lorazepam and diazepam can be given parenterally, which is good for patients who cannot receive oral medications.

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