Alcoholism is a bigger issue that we like to acknowledge. From the individuals with opioid use disorder to patients with longstanding psychiatric history, their medical issues are often coupled with concerns for chronic alcoholism. There are often limited inpatient detoxification programs available in the community. As such, options for outpatient detox program are more versatile to consider and implement especially for individuals who are in mild withdrawal (e.g. CIWA-AR below 8).
The use of benzodiazepines has been a mainstay therapy but it can be challenging to use in an outpatient setting, especially with risk of diversion, concurrent use with alcohol or oversedation. Hence the use of anticonvulsant as an alternative option has been gaining popularity. Anticonvulsants also have some added benefits in preventing seizure which can be a complication for individuals in alcohol withdrawal. Below are two regimens that have been studied in clinical trials:
- Carbamazepine 200mg po four times daily on Day 1
- Carbamazepine 200mg po three times daily on Day 2
- Carbamazepine 200mg po twice daily on Day 3
- Carbamazepine 200mg po daily for 2 more days
This regimen has been compared with benzodiazepines. In one study, carbamazepines was found to be superior to oxazepam in relieving global psychological distress and reducing aggression and anxiety and relieving rebound withdrawal symptoms. In another study, carbamazepine was superior to lorazepam in preventing rebound withdrawal symptoms and reducing post-treatment drinking.
The drawback of carbamazepines is that it interacts with many medications and may cause hyponatremia and otherwise, it can be considered as a reasonable alternative in an outpatient alcohol detox regimen.
The use of gabapentin in alcohol withdrawal management has been investigated in many studies using various regimens over the years. More recently, the following gabapentin regimen at doses up to 1800mg/day in a 12 week period has been demonstrated to be most efficacious as compared to placebo and lower dose of gabepentin dose (900mg/day) in a randomized controlled study. In this study, gabapentin significantly improved the rates of abstinence and no heavy drinking.
- Week 0, day 1: Gabapentin 300mg x 1
- Week 0, day 2: Gabapentin 300mg BID
- Week 0, day 3: Gabapentin 300mg TID
- Week 0, day 4: Gabapentin 300mg BID and 600mg qhs
- Week 0, day 5: Gabapentin 600mg qam, 300mg qnoon, 600mg qhs
- Week 0, day 6-7: Gabapentin 600mg TID
- Week 1-10, continue Gabapentin 600mg po TID
- Week 11, day 1: Gabapentin 600mg qam, 300mg qnoon, 600mg qhs
- Week 11, day 2: Gabapentin 300mg po BID, 600mg qhs
- Week 11, day 3: Gabapentin 300mg TID
- Week 11, day 4: Gabapentin 300mg BID
- Week 11, day 5: Gabapentin 300mg daily
- Week 11, day 6-7: No gabapentin
Gabapentin may be another versatile option, given it also has a role in neuropathic pain as well as mood stabilizer. For individuals with chronic pain and / or mood disorder who may also require alcohol detox in the community, gabapentin may offer to serve many purposes. The down side to gabapentin is its complicated titration schedule that may be difficult to follow as well as its sedative properties.
Other anticonvulsants that may have some preliminary evidence in managing alcohol withdrawal include pregabalin, topiramate and levetiracetam.
In addition, varencicline which is a nicotine agonist and officially indicated for smoking cessation has some data suggesting it reduces alcohol cravings and consumption at regimen of Varencicline 1mg po BID for 12 weeks.
During alcohol withdrawal, it is important to supplement with Thiamine 100mg po daily and may consider folic acid 1mg as well as mutlivitamins. For relapse prevention agents, acamprosate and naltrexone are available to consider after the detoxification period is complete.
Many patients in the community may have various medical issues and mental health concerns, for which the addition of chronic alcoholism can complicate strategies for management. The anticonvulsant option for alcohol detox may offer creative opportunities in the community to address some of these issues simultaneously. At present, gabapentin seems to have the strongest evidence but I suspect it won’t be long before we may be able to consider pregabalin or topiramate as well.
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