Mental health

Management of alcohol withdrawal

Question 2: What interventions are safe and effective for the management of alcohol withdrawal, including treatment for alcohol withdrawal seizures and prevention and treatment for acute Wernicke's encephalopathy?

Management of alcohol use disorder

  • Population: people with alcohol dependence commencing alcohol withdrawal
  • Interventions:
    • benzodiazepines
    • anticonvulsants (non sedating i.e. non barbiturates and not chlormethiazole)
    • antipsychotics
  • Comparison: placebo and/or active treatment
  • Outcomes:
    • severity of withdrawal
    • complications of withdrawal (seizures, delirium)
    • completion of withdrawal
    • death.

Recommendation(s)

Supported withdrawal from alcohol should be advised in patients with alcohol dependence, as a precursor to treatment.
Strength of recommendation: STRONG

Benzodiazepines are recommended as front-line medication for the management of alcohol withdrawal in alleviating withdrawal discomfort, and preventing seizures and delirium. Long-acting benzodiazepines are recommended over shorter-acting ones, except in cases of impaired hepatic metabolism (e.g. liver failure, elderly). The dose and duration should be individually determined, according to the severity of withdrawal and the presence of other medical disorders. In general, the duration of benzodiazepines treatment should be limited to the first 3 to 7 days after the cessation of alcohol.
Strength of recommendation: STRONG

Antipsychotic medications should not be used as stand alone medications for the management of alcohol withdrawal.
Strength of recommendation: STRONG

Benzodiazepines, and not anticonvulsants, should be used following an alcohol withdrawal seizure for the prevention of further alcohol withdrawal seizures.
Strength of recommendation: STRONG

Psychoactive medication used for the treatment of alcohol withdrawal should be dispensed in small doses, or each dose supervised, to reduce the risk of misuse.
Strength of recommendation: STRONG

Patients at risk of severe withdrawal, or who have concurrent serious physical or psychiatric disorders, or who lack adequate support, should preferably be managed in an inpatient setting.
Strength of recommendation: STRONG

As part of withdrawal management, all patients should be given oral thiamine. Patients at high risk of Wernicke's Encephalopathy (malnourished, severe withdrawal) should be given 3 days parental thiamine.
Strength of recommendation: STRONG

In patients with suspected Wernicke's Encephalopathy, parenteral thiamine should be administered twice daily for 5 days.
Strength of recommendation: STRONG

Evidence profile

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