Which detoxification regimens are effective for alcohol withdrawal syndrome?
EVIDENCE-BASED ANSWER:
Benzodiazepines remain the first-line regimen for alcohol withdrawal syndrome (AWS) and are the only class more effective than placebo for reducing seizure (strength of recommendation [SOR]: B, based on 3 medium-quality randomized controlled trials [RCTs]). Anticonvulsants are no more effective than placebo at reducing seizures (SOR: B, based on 10 moderate-quality RCTs). Gabapentin reduces withdrawal symptoms and is less sedating than benzodiazepines (SOR: B, based on 1 medium-quality RCT). Carbamazepine also reduces withdrawal symptoms (SOR: B, based on 3 RCTs). Evidence of benzodiazepine superiority to other drugs with respect to safety is lacking (SOR: A, based on a meta-analysis).
Gabapentin is effective; less sedating than chlordiazepoxide
A 2013 RCT of US veterans with AWS (N = 26; 25 men; average age, 53.5 years) compared gabapentin and chlordiazepoxide.3 Endpoints were ratings on the Epworth Sleepiness Scale (ESS; maximum score = 24), Penn Alcohol Craving Scale (PACS; maximum score, 30), and CIWA-Ar.
In the early treatment period (Days 1-4), ESS and PACS scores did not differ significantly between groups. At end of treatment (Days 5-7), ESS and PACS scores were lower in gabapentin-treated patients (ESS: MD = –3.7; 95% CI, –7.2 to –0.19; P = .04; PACS: MD = –6.05; 95% CI –12.82 to 0.72; P = .08). CIWA-Ar did not differ between treatment groups.
Recommendations from others
In January 2020, the American Society of Addiction Medicine (ASAM) published a clinical practice guideline for alcohol withdrawal management. Protocols for diagnosis, assessment, level of care determination, and management are delineated.4
Benzodiazepines are the first-line treatment for moderate-to-severe AWS, or when there is risk for severe AWS. In the ambulatory setting, when AWS is mild and there is no risk for worsening, AWS can be managed with supportive care or with either benzodiazepines, gabapentin, or carbamazepine as monotherapy. ASAM recommends long-acting benzodiazepines (eg, chlordiazepoxide or diazepam) over short-acting benzodiazepines (eg, alprazolam or lorazepam), except in the elderly and those with liver or lung disease.5
Editor’s takeaway
Dozens of small trials and meta-analyses confirm the benefits (sometimes marginal) of sedation to treat alcohol withdrawal. Given that the evidence fails to point to the superiority of 1 agent over another, it seems reasonable to make treatment decisions based on physician and perhaps patient preference. This review does not support a change in clinical practice.
