Expansion
Long acting benzodiazepine plus thiamine, with seizure and delirium risk
Expansion
Timeline
- 6 to 12 hours: tremor, sweating, anxiety, nausea
- 12 to 48 hours: withdrawal seizures, generalised tonic-clonic
- 48 to 72 hours: delirium tremens, with confusion, hallucinations, autonomic instability and a mortality of several per cent untreated
Mechanism: chronic alcohol enhances GABA and inhibits NMDA; withdrawal leaves unopposed glutamatergic excitation.
Treatment
- Chlordiazepoxide or diazepam, typically by a symptom-triggered or reducing regimen. The long half-life gives a self-tapering effect
- Lorazepam if there is significant liver impairment, since it has no active metabolites
- Parenteral thiamine (Pabrinex) to prevent Wernicke encephalopathy, given before glucose
- Fluids, electrolyte correction including magnesium, and monitoring for other causes of confusion
Do not use antipsychotics as first line, since they lower the seizure threshold and do not treat the underlying deficit; they may be added for hallucinations once benzodiazepines are adequate.
Long term: acamprosate, naltrexone or disulfiram alongside psychosocial support.