16
Treatment – Ambulatory
D. Pharmacotherapy
(1) Prophylaxis
Î Recommendation IV.13: Patients at risk of developing severe
or complicated alcohol withdrawal or complications of alcohol
withdrawal may be treated in ambulatory settings at the discretion
of providers with extensive experience in management of alcohol
withdrawal. Such patients should be provided with preventative
pharmacotherapy. Benzodiazepines are first-line treatment because
of their well-documented effectiveness in reducing the signs and
symptoms of withdrawal including the incidence of seizure and
delirium. Phenobarbital is an appropriate alternative in a Level 2-WM
setting for providers experienced with its use. For patients with a
contraindication for benzodiazepine use, phenobarbital (in Level 2-WM
settings by providers experienced with its use) or transfer to a more
intensive level of care are appropriate options.
Î Recommendation IV.14: A front-loading regimen is recommended for
patients at high risk of severe withdrawal syndrome. Providing at least
a single dose of preventative medication is appropriate for patients at
lower levels of risk who have:
• A history of severe or complicated withdrawal
• An acute medical, psychiatric, or surgical illness
• Severe coronary artery disease
• Displaying signs or symptoms of withdrawal concurrent with a positive blood
alcohol content
Î Recommendation IV.15: Patients at risk of developing new or
worsening signs or symptoms of withdrawal while away from
the ambulatory treatment setting should be provided with
pharmacotherapy. Some indications of risk include a history of
withdrawal episodes of at least moderate severity and being within
the window for the development of symptoms in the time course of
withdrawal. Benzodiazepines, carbamazepine, or gabapentin are
all appropriate options for monotherapy. Providing at least a single
dose of benzodiazepine followed by ongoing treatment according to
symptom severity is also appropriate. If the risk of developing worse
withdrawal is unknown, patients should be reassessed frequently over
the next 24 hours to monitor their need for withdrawal medication.
