Clinical Question

Are benzodiazepines safe and effective for the treatment of alcohol withdrawal?

Evidence-Based Answer

Benzodiazepines are safe and effective for the treatment of alcohol withdrawal, particularly for the prevention of withdrawal seizures, although their superiority to anticonvulsants has not been demonstrated convincingly. There is no clear benefit of one benzodiazepine over another or of symptom-triggered versus fixed-dose scheduling.

Practice Pointers

Benzodiazepines are used widely for the treatment of alcohol withdrawal, with the goals of reducing the severity of withdrawal, preventing delirium, and reducing the incidence of seizures. This systematic review identified 57 relevant randomized controlled trials with a total of 4,275 participants. The quality of the included studies, many of which date from the 1970s and 1980s, was fair, and most were small. Only nine studies clearly concealed allocation of patients to treatment or control groups, and only 21 adequately described the randomization procedures, although all but three were double-blinded.

Not surprisingly, the authors found that benzodiazepines were much more effective than placebo at preventing alcohol withdrawal seizures (relative risk 0.16; 95% confidence interval, 0.04 to 0.69). However, there was no significant difference in prevention of seizure between benzodiazepines and antiseizure drugs. There also was no difference in control of symptoms (as measured by standard scales) among benzodiazepines and other drugs such as clonidine (Catapres) or carbamazepine (Tegretol). There were trends in favor of benzodiazepines, particularly longer-acting drugs, for prevention of delirium. Thirteen studies, with a total of 571 patients, compared different benzodiazepines but found no differences in effectiveness among them. Only three studies, with a total of 262 patients, compared fixed-dose with symptom-triggered dosing schedules, and no clear conclusions could be drawn.

An evidence-based guideline from the American Society of Addiction Medicine¹ recommends benzodiazepines as a first-line agent for the treatment of alcohol withdrawal. The guideline notes that although agents with a longer duration of action may provide fewer breakthrough symptoms, those with a shorter duration of action, such as lorazepam (Ativan), may be preferred when there is concern about prolonged sedation (e.g., in patients with significant comorbidities or liver disease).¹