## First-Line Management of Acute Alcohol Withdrawal **Key Point:** Benzodiazepines are the gold-standard first-line pharmacotherapy for acute alcohol withdrawal syndrome (AWS), including both autonomic hyperactivity and seizure prophylaxis. ### Mechanism of Action Benzodiazepines potentiate GABA~A~ receptor signalling, which is downregulated in chronic alcohol use. They: - Suppress autonomic hyperactivity (tremor, tachycardia, diaphoresis, agitation) - Prevent and treat withdrawal seizures - Reduce progression to delirium tremens ### Choice of Agent | Feature | Lorazepam | Diazepam | | --- | --- | --- | | **Route** | IV/IM/PO | IV/PO | | **Onset** | Rapid (IM/IV) | Very rapid (IV) | | **Metabolism** | Hepatic conjugation (safer in liver disease) | Hepatic oxidation (active metabolites) | | **Half-life** | 10–20 hrs | 20–70 hrs | | **Preference** | First-line in most settings, especially cirrhosis | Acceptable alternative | **High-Yield:** Lorazepam is preferred in patients with hepatic impairment because it undergoes conjugation (not oxidation) and produces no active metabolites. ### Clinical Pearl The **CIWA-Ar scale** (Clinical Institute Withdrawal Assessment for Alcohol) guides symptom-triggered dosing, reducing total benzodiazepine exposure and risk of over-sedation compared to fixed schedules. ### Seizure Prophylaxis Benzodiazepines alone are sufficient for seizure prevention in AWS; prophylactic phenytoin is NOT indicated and does not prevent alcohol withdrawal seizures. [cite:Harrison 21e Ch 391]
Sign up free to access AI-powered MCQ practice with detailed explanations and adaptive learning.