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.
