Considerations before starting benzodiazepines for alcohol withdrawal

For discussion of the role of benzodiazepines in managing alcohol withdrawal, see Overview of alcohol withdrawal management. Before starting a benzodiazepine regimen for alcohol withdrawal, review local guidelines; specialist advice is available from clinical advisory services to discuss queries.

Benzodiazepine treatment is contraindicated in hepatic encephalopathy because it can cause serious exacerbation. Hepatic encephalopathy results from severe liver disease and typically causes sedation (sometimes coma), obscuring the presentation of acute alcohol withdrawal; specialist advice is recommended for any patient with hepatic encephalopathy.

Diazepam is usually preferred for managing alcohol withdrawal because it has a long duration of action. It should be given early because withdrawal escalates during the first 24 to 48 hrs, and peaks by 48 to 72 hours. Diazepam is not recommended for patients with chronic liver disease (Child–Pugh class B or C); it has active metabolites that accumulate in these patients. Lorazepam or oxazepam, can be used instead for inpatients to reduce the risk of sedation or delirium; seek specialist advice.

Midazolam (by intravenous injection or infusion) is preferred if rapid but easily reversible sedation is required during hospital management of alcohol withdrawal (eg for a patient in an emergency department with recent seizure and with suspected head injury)Haber, 2021.