›Day 4: 10 mg PO qHS (10 mg/day)
›Chlordiazepoxide 50–100 mg PO q6h as alternative
›Severe withdrawal (CIWA-Ar >= 19) — IV loading protocol
›Diazepam 5–10 mg IV q10–15 minutes until adequate sedation
›Target: CIWA-Ar < 10 or sedation score 2–3
›No predetermined maximum for life-threatening withdrawal
›Cumulative doses of 100–200 mg may be required in severe DT
›Lorazepam 2–4 mg IV q10–15 minutes as alternative
›Preferred in liver disease and elderly (no active metabolites)
›Titrate to same sedation target
›Respiratory monitoring mandatory with IV loading
›RSI preparation if respiratory depression occurs
›Second-line or adjunct therapy
›Indications
›Benzodiazepine-resistant withdrawal
›Adjunct to reduce total benzodiazepine dose
›Alternative monotherapy in select settings
›Dosing
›130–260 mg IV q15–20 minutes PRN (loading)
›Maximum loading dose typically 20 mg/kg
›Sedation, respiratory depression monitoring essential
›Maintenance: 30–60 mg PO/IV q8–12h after loading
›Evidence
›Reduces mechanical ventilation rates in refractory DT
›Long half-life (80–120 hours) provides smooth withdrawal coverage
›ACEP supports use in refractory withdrawal (Level B recommendation)
›Mild-to-moderate withdrawal alternative
›Dosing for mild withdrawal
›300–600 mg PO TID for 3–5 days
›Total daily dose: 900–1800 mg/day
›Taper over 3–5 days
›Advantages: no abuse potential, treats AUD long-term
›Limitations
›Not effective for seizure prevention in severe withdrawal
›Do not use as monotherapy for CIWA-Ar >= 19
›Not recommended in renal failure without dose adjustment
›Evidence
›Non-inferior to lorazepam for outpatient mild-moderate withdrawal (Level B)
›Alternative for mild-moderate withdrawal
›Dosing
›200 mg PO TID for 5–7 days (mild) or BID-TID for moderate
›Maximum 1200 mg/day
›Taper over 7 days
›Advantages
›Effective for preventing seizures and reducing symptom severity
›No abuse potential
›Contraindications
›Bone marrow suppression history
›Hepatic failure
›Drug interactions (CYP3A4 inducer)
›Active withdrawal seizure
›Immediate benzodiazepine administration
›Lorazepam 2–4 mg IV first choice
›Repeat in 5–10 minutes if seizure continues
›Diazepam 5–10 mg IV alternative
›Rectal diazepam 10–20 mg if no IV access
›Phenobarbital for benzodiazepine-refractory seizure
›20 mg/kg IV loading dose
›Airway management standby required
›Phenytoin: NOT indicated for withdrawal seizures
›No evidence of benefit for withdrawal-related seizures
›ASAM 2020 guideline: do not use phenytoin for AWS seizures
›Post-seizure evaluation
›CT head for first-time seizure or atypical features
›Anticipate delirium tremens (one-third of seizure patients progress)
›Symptom-specific adjuncts
›Dexmedetomidine (ICU setting)
›Reduces opioid and benzodiazepine requirements in refractory DT
›0.2–0.7 mcg/kg/hour IV infusion
›Bradycardia and hypotension monitoring required
›Does not prevent seizures; never use as monotherapy
›Clonidine
›0.1–0.2 mg PO/IV q6h for autonomic symptoms
›Reduces tachycardia and hypertension
›Does not prevent seizures or delirium
›Beta-blockers: AVOID in withdrawal
›Do not lower seizure threshold risk
›Mask autonomic signs used for CIWA-Ar scoring
›Avoid unless concurrent cardiac indication requiring them
Nutritional supplementation
›Vitamin and mineral replacement
›Thiamine
›Hospitalized patients: 500 mg IV TID for 3 days, then 100 mg IV daily
›Outpatient: 100 mg PO daily for 3–5 days minimum
›Must precede any glucose administration
›Folate
›1 mg PO daily (often deficient in AUD)
›Multivitamin
›Daily oral multivitamin supplementation
›Zinc
›220 mg PO daily if suspected deficiency