East Region Formulary

10-40mg four times daily titrated to response, gradually reducing over 5 to 7 days.

Prescribing Notes:

Alcohol dependent patients exhibiting moderate to severe withdrawal features or those assessed at high risk of developing severe withdrawal symptoms should be prescribed benzodiazepines for detoxification.
In most patients the symptoms of alcohol withdrawal are mild to moderate and disappear 5-7 days after the last drink. In more severe cases (approximately 5%) DTs may develop.
A number of factors influence the decision to detox in the community setting or as an inpatient. The specialist team will provide support, if necessary/appropriate, in making this decision. Outpatient detox is appropriate for patients with mild to moderate withdrawal symptoms.
The dose and duration of treatment required will depend upon, the degree of dependence on alcohol and the severity of the withdrawal symptoms.
Benzodiazepines have dependence potential. To minimise risk of dependence, administer short-term only.
Benzodiazepines should not be prescribed if the patient is likely to drink alcohol concomitantly.
Prescribe reduced doses if the patient has: low body weight; been drinking for less than 3 weeks in current bout; no seizure history.
Caution needs to be exercised when benzodiazepines are prescribed in older patients, and in renal or liver impairment since accumulation may result in oversedation.
Review use daily.
Choice of benzodiazepines:
- Chlordiazepoxide is first choice oral agent for outpatients and general practice alcohol withdrawal, because it has less abuse potential and ‘street value’ than diazepam.
- Diazepam is the benzodiazepine of choice in secure environments, due to the longer duration of action.
- Chlordiazepoxide tablets are substantially more expensive than capsules.
All patients undergoing alcohol detoxification should receive vitamin supplementation. See ‘Vitamin supplementation for patients with alcohol dependence or undergoing alcohol detoxification’ pathway.
Seek specialist advice for use of adjunctive treatments.
Following successful alcohol detoxification, relapse may be prevented by prescribing treatments for maintenance of alcohol abstinence (see ‘Maintenance of alcohol abstinence’ pathway for treatment options).

History Notes

27/10/2022

East Region Formulary content agreed.

Refer to local in-patient alcohol withdrawal protocol for standard dose regimen. Dose is titrated according to response up to 250mg in divided doses over 24 hours. Seek specialist advice if more than 250mg in 24 hours is required. Dose is gradually reduced over 5 to 7 days.

Refer to local in-patient alcohol withdrawal protocol for standard dose regimen and instruction on when to seek specialist review. Dose is gradually reduced over 5-7 days. See prescribing notes if a supply is required on discharge.

Restricted to use in severe liver impairment, specialist use only. Injection restricted to use where the oral route is unavailable.

On specialist advice.

Restricted to use where the oral route is unavailable or in patients with severe agitation – refer to inpatient alcohol withdrawal protocol.

For dose refer to inpatient alcohol withdrawal protocol.

Prescribing Notes:

Alcohol dependent patients exhibiting moderate to severe withdrawal features or those assessed at high risk of developing severe withdrawal symptoms should be prescribed benzodiazepines for detoxification.
In most patients the symptoms of alcohol withdrawal are mild to moderate and disappear 5-7 days after the last drink. In more severe cases (approximately 5%) DTs may develop.
A number of factors influence the decision to detox in the community setting or as an inpatient. The specialist team will provide support, if necessary/appropriate, in making this decision.
The dose and duration of treatment required will depend upon, the degree of dependence on alcohol and the severity of the withdrawal symptoms.
Benzodiazepines have dependence potential. To minimise risk of dependence, administer short-term only.
Benzodiazepines should not be prescribed if the patient is likely to drink alcohol concomitantly.
Prescribe reduced doses if the patient has: low body weight; been drinking for less than 3 weeks in current bout; no seizure history.
Caution needs to be exercised when benzodiazepines are prescribed in older patients or patients with renal or liver impairment since accumulation may result in oversedation.
For in-patients refer to relevant local alcohol withdrawal protocols.
Review use daily.
Choice of benzodiazepines:
- Chlordiazepoxide tablets are substantially more expensive than capsules.
- Diazepam or chlordiazepoxide are used for in-patients (as per local protocol). A reducing course over 2 to 3 days may be prescribed by a hospital clinician on discharge.
- Diazepam is the benzodiazepine of choice in secure environments, due to the longer duration of action.
- If oral diazepam is used for alcohol detoxification in the acute setting and a supply is required on discharge to complete the detox regime, the supply can be given as chlordiazepoxide (which has less abuse potential in the community); Diazepam 5mg is approximately equivalent to 10mg chlordiazepoxide.
- Diazepam is first choice for in-patients if the parenteral route is required.
- In liver failure, oxazepam or lorazepam may be considered due to the shorter duration of action, use reduced dose for liver impairment and monitor LFTs.
All patients undergoing alcohol detoxification should receive vitamin supplementation. See ‘Vitamin supplementation for patients with alcohol dependence or undergoing alcohol detoxification’ pathway.
Seek specialist advice for use of adjunctive treatments.
Following successful alcohol detoxification, relapse may be prevented by prescribing treatments for maintenance of alcohol abstinence (see ‘Maintenance of alcohol abstinence’ pathway for treatment options).

History Notes

11/05/2023

Diazemuls 10mg/2ml emulsion for injection ampoules discontinued and removed from the pathway, ERWG May 23.

27/10/2022

East Region Formulary content agreed.

These treatments are an adjunct to counselling.

18-65 years, 60kg and above, 666mg 3 times daily;
under 60kg, 666mg at breakfast, 333mg at midday and 333mg in early evening.

25mg once daily on the first day then increased if tolerated to 50mg daily.

Reserved for use when first choice agents are not suitable or where there is individual preference with an understanding of the relative risks. This treatment is an adjunct to counselling. An off-label dose regimen of three times a week disulfiram may be considered for supervised self-administration.

200mg daily, increased if necessary up to 500mg daily.
An alternative off-label dose regimen of three times a week disulfiram may be considered for supervised self-administration, e.g. 400mg on Monday, 400mg on Wednesday and 600mg on Friday.
Not to be continued for longer than 6 months without review.

This treatment is an adjunct to counselling. For use in patients who have a high drinking risk level (DRL) without physical withdrawal symptoms and who do not require immediate detoxification. Nalmefene should only be initiated in patients who continue to have a high DRL two weeks after initial assessment.

18mg daily if required, taken on each day there is a risk of drinking alcohol.

Restricted to patients where other licensed treatments are ineffective, contra-indication or not tolerated.

On specialist advice.

Prescribing Notes:

Before initiating treatment, prescribers should evaluate the patient’s clinical status, alcohol dependence, and level of alcohol consumption. Choice of treatment will be influenced by patient acceptability.
Relapse prevention medication should be considered only after the patient has been fully assessed and are motivated to prevent relapse with psychosocial interventions focused on alcohol misuse.
After a successful withdrawal for people with moderate and severe alcohol dependence, treatment choices for consideration include acamprosate, oral naltrexone or disulfiram. Nalmefene can be considered in patients who have a high drinking risk level (DRL) without physical withdrawal symptoms and who do not require immediate detoxification.
Acamprosate reduces the risk of relapse by suppressing the “urge to drink” in response to learned triggers. It should be initiated as soon as possible after detoxification and if assessed to be effective (i.e. there is a major reduction in drinking) continued for a minimum of 6 months. Recommended treatment period is 1 year. Treatment with acamprosate should not be stopped if there is a minor relapse. Repeated relapsing to heavy drinking indicates non-efficacy. Treatment may be continued longer term with regular reviews every six months.
Naltrexone is used as an adjunct in patients to prevent relapse, after successful withdrawal. Use is restricted to patients with no history of liver problems, substance misuse or opioid dependence. Patients should be reviewed at least every 6 months.
Disulfiram is prescribed for patients who would benefit from a deterrent, particularly if they can nominate a partner who can help them to take it regularly.
Patients receiving disulfiram suffer unpleasant systemic reactions if alcohol is consumed.
Disulfiram self-administration should be supervised by, for example, a partner or an appropriate nurse, or at a day hospital. There is no evidence supporting unsupervised consumption.
For patients successfully maintaining abstinence with disulfiram treatment should be continued for a minimum of 6 months but may be continued longer-term with regular reviews every 6 months.
During treatment with Nalmefene patients should be monitored regularly and the need for continued treatment assessed. Caution is advised if treatment is continued for more than 1 year.

History Notes

27/10/2022

East Region Formulary content agreed.

Pabrinex should be administered in hospitals or health centres where facilities for treating anaphylaxis are available.

By intravenous infusion 2-3 pairs 3 times a day for 3-5 days, followed by 1 pair once daily for a further 3-5 days or for as long as improvement continues.

Prescribing Notes:

Refer to local alcohol withdrawal protocols.
Patients with any sign of Wernicke-Korsakoff syndrome must be given treatment doses of parenteral vitamins (Pabrinex) in hospital. Signs include confusion, ataxia, ophthalmoplegia/nystagmus, memory disturbance, hypothermia and hypotension, coma/unconsciousness.

History Notes

27/10/2022

East Region Formulary content agreed.

All patients undergoing alcohol detoxification are recommended to receive vitamin supplementation with pabrinex. Pabrinex is given for prophylaxis to people at risk of Wernicke’s encephalopathy. Pabrinex should be administered in hospitals or health centres where facilities for treating anaphylaxis are available.

By deep intramuscular injection 1 pair once daily for duration refer to local specialist guidance, give into the gluteal muscle.

By intravenous infusion, for dose and duration refer to local specialist guidance.

Oral thiamine may be offered to patients who are malnourished or at risk of malnourishment or have decompensated liver disease. In patients undergoing alcohol detoxification who are receiving Pabrinex for prophylaxis of Wernike’s encephalopathy oral thiamine may be offered after completion of the course of Pabrinex.

100mg three times daily.

Prescribing Notes:

Refer to local alcohol withdrawal protocols.
All patients undergoing alcohol detoxification are recommended to receive vitamin supplementation with parenteral vitamins B and C.
Prophylactic doses of parenteral vitamins (Pabrinex) should be given to patients at risk of Wernicke-Korsakoff syndrome e.g. those with recent diarrhoea, vomiting, poor diet, other physical illness or signs of weight loss or malnutrition. The patient may have been consuming more than 20 units of alcohol per day.
Oral thiamine supplementation may be considered for patients who are malnourished or at risk of malnourishment or have decompensated liver disease. More research is required to confirm the optimal dose and duration. The potential benefit of preventing thiamine deficiency might outweigh the low risks. Local specialists recommend thiamine 100mg three times daily for optimal absorption.
Vitamin B compound strong tablets are not recommended for use in alcohol misuse patients due to lack of evidence of efficacy.

History Notes

27/10/2022

East Region Formulary content agreed.