Template:Inpatient management of ETOH withdrawal

Benzodiazepine overview

Agents	Equivalent PO dose (mg)	Route	Onset of Action (min)	Half Life (hr)	Metabolism
Chlordiazepoxide	25	PO, IV	30 - 120	7-28	CYP; active metabolites
Diazepam	5	PO, IV, IM	2 - 5	20-120	CYP; active metabolites
Lorazepam	1	PO, IM, IV	15-20	8-19	Glucuronidation

Benzodiazepines

• Diazepam (Valium) 5-10 mg IV (depending on severity)
  • May repeat q5-10 min for severe withdrawal (may increase dose by 10 mg every 5-10 min until desired effect achieved, max dose of 200 mg)
  • Half-life 20-100 h (long acting)
• Lorazepam (Ativan) 1-4mg IV (depending on severity)
  • May repeat q15-20 min for severe withdrawal (titrated to effect)
  • Rarely causes hepatitis, as opposed to diazepam which may cause a cholestatic hepatitis
  • Half-life 10-20 h (medium acting)

Other Agents

For use in cases refractory to benzodiazepine treatment

• Propofol
  • If patient does not respond to high doses of benzodiazepines
  • 0.3-1.25 mg/kg up to 4 mg/kg/hr (consider intubation), for up to 48 hours
• Barbiturates (Phenobarbital)
  • Used when refractory to benzodiazepines (consider after patient has received equivalent of 200 mg diazepam)
    • Phenobarbital 130-260 mg IV q 15-20 minutes
    • Can also be used as a first line load at 10 mg/kg prior to giving benzodiazepines to decrease benzodiazepine requirements and ICU admissions
• α-2 agonists (Dexmedetomidine)
  • Decrease severity of symptoms, but only supplemental to GABA-ergic first-lines
  • Dexmedetomidine drip, start 0.2 mcg/kg/min, likely needing no more than 0.7 mcg/kg/min
• Ketamine
  • May have some use in refractory cases
  • Blocks the NMDA receptor which is excited an unregulated.

Special Situations

• The propylene glycol diluent in lorazepam, phenobarbital, and diazepam, may induce a hyperosmolar anion gap metabolic acidosis if given as a drip in high doses ≥ 48hrs. Consider alternatives such as propofol or dexmedetomidine if patients need long term sedation for delirium tremens.