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D. Pharmacotherapy
(1) Prophylaxis
Î Recommendation V.13: For patients at risk of developing severe
or complicated alcohol withdrawal or complications of alcohol
withdrawal, preventive pharmacotherapy should be provided.
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. For
patients with a contraindication for benzodiazepine use, phenobarbital
can be used by providers experienced with its use. In settings with
close monitoring, phenobarbital adjunct to benzodiazepines is also
appropriate.
Î Recommendation V.14: A front loading regimen is recommended for
patients at high risk of severe withdrawal syndrome. Providing at least
a single dose of preventive medication is appropriate for patients at
lower levels of risk not experiencing significant signs or symptoms but
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
(2) Withdrawal symptoms
Î Recommendation V.15: For patients experiencing mild alcohol
withdrawal (e.g., CIWA-Ar score <10) who are at minimal risk of
developing severe or complicated alcohol withdrawal or complications
of alcohol withdrawal, pharmacotherapy or supportive care alone may
be provided. If providing medication, benzodiazepines, carbamazepine,
or gabapentin are appropriate. For patients with a contraindication for
benzodiazepine use, carbamazepine, gabapentin, or phenobarbital (for
providers experienced with its use), are appropriate. Carbamazepine,
gabapentin, or valproic acid (if no liver disease or childbearing
potential) may be used as an adjunct to benzodiazepines.
Î Recommendation V.16: Patients experiencing moderate
alcohol withdrawal (e.g., CIWA-Ar scores 10–18) should receive
pharmacotherapy. Benzodiazepines are first-line treatment.
Carbamazepine or gabapentin are appropriate alternatives.
For patients with a contraindication for benzodiazepine use,
carbamazepine, gabapentin, or phenobarbital (for providers
experienced with its use) are appropriate. Carbamazepine, gabapentin,
or valproic acid (if no liver disease or childbearing potential) may be
used as an adjunct to benzodiazepines.
