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Characteristic withdrawal syndrome develops within hours to days after cessation or reduction of heavy and prolonged alcohol use r3
Earlier medical history may be significant for: r4
Psychiatric history
Factors that may modify withdrawal symptoms or course
Presence of comorbidity
Acute withdrawal may progress in stages ranging in severity from mild to severe r15
General criteria for outpatient management r10
General criteria for discharge with referral for outpatient alcohol dependence treatment program
General criteria for outpatient detoxification
Admission criteria to medical unit or inpatient medically supervised detoxification center r4
Resuscitation and stabilization is first aspect of care while assessing need for treatment of concurrent medical conditions r2
Determine level of care and setting necessary for appropriate management
Regional protocols are available to guide management strategy for both inpatient and outpatient treatment r22
Standard inpatient alcohol withdrawal treatment with medical assistance r6
Outpatient alcohol withdrawal treatment with medical assistance
Counseling and rehabilitation
Drug | Time to onset | Active metabolites | Half-life in hours | Typical initial dose |
---|---|---|---|---|
Diazepam | 1 to 5 minutes intravenous | Yes | 43 ± 13 | 10 to 20 mg intravenous or oral |
Lorazepam | 5 to 20 minutes intravenous | No | 14 ± 5 | 2 to 4 mg intravenous or oral |
Midazolam | 2 to 5 minutes intravenous/intramuscular | Yes | 2 ± 1 | 2 to 4 mg intravenous or intramuscular |
Oxazepam | 2 to 3 hours oral | No | 8 ± 2 | 15 to 30 mg oral every 8 hours |
Chlordiazepoxide | 2 to 3 hours oral | Yes | 10 ± 3 | 50 to 100 mg oral |
Chlordiazepoxide | Diazepam | Lorazepam | Midazolam | Phenobarbital | Propofol | |
---|---|---|---|---|---|---|
Class of drug | Benzodiazepine | Benzodiazepine | Benzodiazepine | Benzodiazepine | Barbiturate | Hypnotic |
Intermittent initial dose | 50 to 100 mg (oral)* | 10 mg (intravenous) | 2 mg (intravenous) | 1 to 5 mg (intravenous) | 65 mg (intravenous) | Not applicabler61 |
Route of dose | Oral | Intravenous, intramuscular, oral, rectal | Intravenous, intramuscular, oral | Intravenous, intramuscular, oral | Intravenous, intramuscular, oral, rectal | Intravenous |
Infusion dosing | Not applicable | Not applicable | 1 to 4 mg/hour†r56 | 1 to 20 mg/hour, titrate up to effect§ | 10 mg/kg intravenous over 30 minutes**r2 | 0.3 to 6 mg/kg/hour as needed for appropriate sedationr61 |
Time to effect onset | 2 to 3 hours | 1 to 5 minutes (intravenous); 15 to 30 minutes (intramuscular); 30 to 90 minutes (oral); 10 to 45 minutes (rectal) | 5 to 20 minutes | 2 to 5 minutes | 5 to 30 minutes (peak brain concentrations at 20 to 40 minutes) | 1 to 2 minutes |
Half life | 5 to 30 hours (active metabolite 30 to 200 hours) | 30 to 60 hours (active metabolite 30 to 100 hours) | 9 to 21 hours | 2 to 6 hours | 50 to 140 hours | 10 minutes to 12 hours (longer if prolonged use) |
Duration of action | Long | Long | Short to medium | Short | Long | Short to medium |
Metabolism | Hepatic | Hepatic | Hepatic | Hepatic, gut | Hepatic | Hepatic |
Excretion | Renal | Renal | Renal, fecal | Renal | Renal | Renal |
Dose adjustment | Renal (creatinine clearance less than 10): 50% dose reduction; hepatic impairment: risk of accumulation | Hepatic impairment; renal impairment | Renal impairment: dose reduction | Renal failure (creatinine clearance less than 10): dose reduction | Renal failure (GFR less than 10): increase dosing interval and dose reduction; caution in hepatic impairment | None |
Notes | Extremely long-acting active metabolite, so not recommended in elderly patients | Phlebitis; erratic absorption if given intramuscularly | If more than 25 mg/hour, risk of acute tubular necrosis, lactic acidosis, and hyperosmolar state because of solvent; no active metabolite | Prolonged sedation if obese and/or low albumin; active metabolite | May cause hypotension | Risks: propofol infusion syndrome, injection site pain, hypertriglyceridemia; more hypotension than other sedative-hypnotics; may discolor urine. Caution: soy or egg allergy |
Nutrition r4