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Describe the rational for the types of withdrawal treatments and the medications used.

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  • The primary goal of treatment for alcohol withdrawal is to counter act the neurobiologic abnormalities caused by long term alcohol exposure until homeostatic mechanisms can restore normal balanced functioning. Since during withdrawal the major problem is increased nervous system excitability due to increased NMDA mediated glutamatergic function, and down regulated inhibitory GABA function, the use of GABA agonists or NMDA antagonists would reduce the increased excitability. GABA agonists particularly benzodiazepines effectively increase GABA function and are the main treatments for alcohol withdrawal. NMDA antagonists, although effective in animal studies, produce many serious side effects and are not used clinically. Anticonvulsant drugs, some of which augment GABA function, are effective in preventing seizures and reducing withdrawal symptoms. There are a number of benzodiazepines and anticonvulsants available for clinical use, and they are listed below.

  • Of the benzodiazepines, chlordiazepoxide and diazepam have a longer half life and may allow a smoother course of withdrawal but because they are metabolized by the liver they may have unpredictable effects in patients with coexisting liver disease. Lorazepam and oxazepam have intermediate half lives and lorazepam metabolism is largely preserved in the cirrhotic liver and it has been shown to be equally effective as chlordiazepoxide or diazepam. A shorter duration of effect may be an advantage when using symptom-triggered treatment.

  • Carbamazepine is as effective as benzodiazepines in treating the symptoms of withdrawal and may be better in preventing rebound withdrawal and post treatment relapse. It is not recommended as a mono therapy for DT’s.

  • The anitglutamatergic drugs lamotrigine, tpiramate and mematine have been found to be superior to placebo but not different than diazepam and they are not in wide use.