25
Î Recommendation V.26: 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 V.27: 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 V.28: If benzodiazepines are contraindicated,
carbamazepine or gabapentin are appropriate alternatives for patients
in mild or moderate withdrawal.
Î Recommendation V.29: 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 V.30: Valproic acid should not be used in patients
who have liver disease or women of childbearing potential.
Î Recommendation V.31: There is insufficient evidence to support the use
of valproic acid as monotherapy for the treatment of alcohol withdrawal.
(6) Phenobarbital
Î Recommendation V.32: Phenobarbital can be used for some patients
in inpatient settings. However, it should be used only by clinicians
experienced with its use, given its narrow therapeutic window and side
effects.
Î Recommendation V.33: In an inpatient setting, phenobarbital
monotherapy (managed by a clinician experienced with its use) is
appropriate for patients with a contraindication for benzodiazepine use
who are experiencing mild, moderate, or severe alcohol withdrawal or
who are at risk of developing severe or complicated alcohol withdrawal
or complications of alcohol withdrawal.
Î Recommendation V.34: In an inpatient setting, if close monitoring
is available, phenobarbital (managed by a clinician experienced
with its use) as an adjunct to benzodiazepines is an option for
patients experiencing severe alcohol withdrawal or who are at risk of
developing severe or complicated alcohol withdrawal or complications
of alcohol withdrawal.
Î Recommendation V.35: Parenteral phenobarbital should be used only
in highly supervised settings (e.g., ICU, CCU) because of risk of over-
sedation and respiratory depression.
