ASAM Pocket Guidelines and Patient Guide

Alcohol Withdrawal Management

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19 (4) Benzodiazepine dosing regimens Î Recommendation IV.27: At short-term observational settings with continuous monitoring (e.g. Level 2-WM), symptom-triggered treatment conducted by trained staff is the preferred benzodiazepine dosing method. Front loading while under clinical supervision or fixed dosing with additional as-needed medication are also appropriate. Î Recommendation IV.28: At settings without extended on-site monitoring (Level 1-WM), symptom-triggered dosing is appropriate if patients or a caregiver can reliably monitor signs and symptoms with a withdrawal severity scale and follow dosing guidance. Otherwise, front loading while under clinical supervision or fixed dosing with additional as-needed medication is appropriate. Î Recommendation IV.29: Front loading is recommended for patients experiencing severe alcohol withdrawal (e.g., CIWA-Ar ≥19). Diazepam and chlordiazepoxide are preferred agents for front loading. Î Recommendation IV.30: When using a fixed-dose schedule, patients' signs and symptoms should still be monitored. A few additional take-home doses can be provided to take as needed. When initiating a fixed-dose regimen, arrange for the patient to be seen the following day to modify the dose if needed. Î Recommendation IV.31: If prescribing a shorter-acting benzodiazepine, using a fixed-dose regimen with a gradual taper may be appropriate to reduce the likelihood of breakthrough and rebound signs and symptoms. (5) Carbamazepine, gabapentin, valproic acid Î Recommendation IV.32: Gabapentin is a favorable choice for treating alcohol withdrawal when a clinician also plans to use it for a patient's ongoing treatment of alcohol use disorder. Î Recommendation IV.33: If benzodiazepines are contraindicated, carbamazepine or gabapentin are appropriate alternatives. Î Recommendation IV.34: Carbamazepine, gabapentin, or valproic acid may be used as an adjunct to benzodiazepine therapy to help control alcohol withdrawal. Before using as an adjunct, clinicians should ensure that an adequate dose of benzodiazepine has been administered. Î Recommendation IV.35: Valproic acid should not be used in patients who have liver disease or women of childbearing potential. Î Recommendation IV.36: There is insufficient evidence to support the use of valproic acid as monotherapy for the treatment of alcohol withdrawal.

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