Alcohol Withdrawal: The Daily PANCE Blueprint
A 52-year-old man is admitted for an ankle fracture. About 36 hours after his last drink, he becomes anxious and diaphoretic, with a coarse tremor of his outstretched hands and visual hallucinations of insects on the wall. His blood pressure is 162/98 mm Hg, pulse is 118/min, and temperature is 37.9°C (100.2°F). He usually drinks a fifth of vodka daily. His liver enzymes are mildly elevated, and his INR and albumin are normal. Which of the following is the most appropriate pharmacotherapy?
A. Chlordiazepoxide
B. Haloperidol
C. Naltrexone
D. Clonidine
E. Disulfiram
Answer and topic summary
The answer is A. Chlordiazepoxide
Benzodiazepines are first-line for alcohol withdrawal. Alcohol enhances GABA-A signaling, and when it stops, the brain is left over-excited; benzodiazepines act at the same receptor, so they control symptoms and have the strongest evidence for preventing withdrawal seizures and delirium tremens. Dosing is usually symptom-triggered using the CIWA-Ar scale. Long-acting agents such as chlordiazepoxide or diazepam give a smoother course; lorazepam or oxazepam are preferred with significant liver disease or in older adults because they have no active metabolites. Give thiamine before glucose to prevent Wernicke encephalopathy. Haloperidol lowers the seizure threshold and is only an add-on for agitation. Clonidine blunts the adrenergic signs but does not prevent seizures or delirium tremens. Naltrexone and disulfiram are for staying sober after withdrawal, not for treating it.
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