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4.3 Benzodiazepines for the management of alcohol withdrawal

In the management of alcohol withdrawal, a benzodiazepine can reduce psychomotor agitation and, used at an early stage, it may prevent progression to more severe symptoms of withdrawal including convulsions and delirium tremens. For less severe symptoms, the benzodiazepine is given orally either as a fixed regimen of tapering doses or according to withdrawal symptoms as and when they arise (‘symptom-triggered therapy’).

The long-acting benzodiazepines chlordiazepoxide and diazepam are licensed for the management of alcohol withdrawal symptoms; both allow smooth tapering down of the dose.

A benzodiazepine can also be used for managing severe symptoms of alcohol withdrawal and may be of value in managing seizures and the potentially life-threatening condition of delirium tremens (characterised by hallucinations, disorientation, agitation, tremor, severe tachycardia, hypertension, fever, drenching sweats, and fluid and electrolyte disturbances). These symptoms are treated in an in-patient setting and generally entail intravenous use of a benzodiazepine.

The dose of benzodiazepine is initially titrated to satisfactorily control withdrawal symptoms while avoiding oversedation.

Alternative causes of the individual’s symptoms should be ruled out carefully—disorders such as meningitis, intracranial haemorrhage, liver failure, metabolic disturbances, gastrointestinal bleeding, and drug overdose can produce symptoms similar to alcohol withdrawal. These disorders may coexist with alcohol withdrawal.

Factors which increase risk

Alcoholism-related severe nutritional deficit as well as marked fluid and electrolyte imbalance can complicate benzodiazepine treatment. Vitamin B deficiency can interfere with recovery and, in particular, thiamine deficiency can lead to the development of the neurological disorder Wernicke-Korsakoff syndrome.

Absorption from the gastrointestinal tract may be impaired in individuals with a prolonged history of alcohol abuse.

The risk of harm from a benzodiazepine is increased in elderly individuals and in liver damage (eg alcoholic cirrhosis).

Those who have become dependent on alcohol as well as on benzodiazepines may require treatment with high doses of a benzodiazepine, which may possibly increase the risk of harm.

Severe withdrawal symptoms call for intravenous use of a benzodiazepine and this may increase the risk of cardiovascular collapse and severe respiratory depression.

Risk-reduction measures

Fluid and electrolyte defects should be corrected, as should nutritional deficiencies.

Early use of a benzodiazepine should be considered to reduce the risk of progression to more severe symptoms.

The dose may need to be reduced in the elderly and those with liver impairment. In some circumstances a long-acting benzodiazepine may not be appropriate and specialist advice should be sought on the selection of an appropriate drug.

During treatment, close clinical monitoring of vital signs is important. Patients with moderate or severe withdrawal symptoms require particularly close observation. Resuscitation facilities should be at hand when a benzodiazepine is given intravenously.

Supplementary drugs may need to be considered to avoid excessive doses of a benzodiazepine, or if a symptom is not amenable to benzodiazepine treatment, or if the benzodiazepine is not proving effective—specialist advice should be sought.

In those with vitamin deficiency, treatment with B vitamins should be started promptly to aid recovery and prevent Wernicke-Korsakoff syndrome. Initially vitamin B substances are often given parenterally (in settings with resuscitation facilities).

For advice on the management of alcohol dependence and alcohol-related complications, consult: