Diazepam regimens for inpatient alcohol withdrawal
In a community residential withdrawal unit or a hospital alcohol and drug unit (where skilled monitoring is available), diazepam for alcohol withdrawal can be administered for planned or unplanned withdrawal in the following ways:
- symptom-triggered method
- loading-dose method (which is sometimes followed by a gradual tapering dose).
The decision about when to start dosing with any of these regimens is ideally guided by blood alcohol concentration (BAC) in conjunction with withdrawal scales. Generally, benzodiazepine dosing is not started until the BAC falls below 0.05% (approximately 10 mmol/L) and is consistently falling and symptoms of withdrawal are presentHaber, 2021.
The symptom-triggered method is usually used in patients presenting in mild to moderate withdrawal or who are planning withdrawal and have no risk factors for severe withdrawal. This method requires staff skilled in monitoring to use a validated alcohol withdrawal scale (eg the Clinical Institute of Alcohol Withdrawal Scale [CIWA-Ar], available at the Insight website). In most individuals, treatment is only required for 24 to 48 hours because symptoms peak during this period. Use of diazepam in this method after 48 hours risks accumulation, oversedation, confusion or delirium. If using the symptom-triggered method to manage alcohol withdrawal, a common example that may be used with a withdrawal scale by staff skilled in monitoring isHaber, 2021:
diazepam 5 to 10 mg orally, 4- to 6-hourly as required to control withdrawal symptoms. Seek specialist advice if scores on the withdrawal scale escalate despite treatment or symptoms persist beyond 24 hours1. diazepam diazepam diazepam
The loading-dose method is recommended for inpatient care for patients who present in severe withdrawal or have risk factors for it, such as a history of complications (eg seizures). This technique reduces withdrawal severity and incidence of seizures if started early. Seizures start as early as 6 hours after the last drink; start diazepam as soon as clinical signs of withdrawal are evident, but not before (to avoid oversedation). If using the loading-dose method to manage alcohol withdrawal, staff skilled in monitoring may useHaber, 2021:
diazepam 20 mg orally, 1- to 2-hourly as required to control withdrawal symptoms, up to a maximum of 60 mg2. diazepam diazepam diazepam
Severe alcohol withdrawal may require loading doses higher than 60 mg (eg doses up to 100 mg in 24 hours). Specialist advice is recommended in this situation because risks of respiratory depression and delirium, and potential need for transfer to an intensive care unit increase at this dose threshold.
Occasionally, a short taper is needed (eg over 2 to 3 days) after use of the loading-dose method. However, if the patient has concurrent benzodiazepine dependence, a longer taper is required; a common approach is to stabilise the patient on a reduced benzodiazepine dose in hospital, followed by a slow taper as an outpatient.