Anticonvulsants
The American Society of Addiction Medicine recommends the use of gabapentin, carbamazepine, or valproic acid as adjunctive treatment in select patient populations with mild alcohol withdrawal syndrome (AWS).[5]American Society of Addiction Medicine. The ASAM clinical practice guideline on alcohol withdrawal management. J Addict Med. 2020 May/Jun;14(3s suppl 1):1-72.
https://www.doi.org/10.1097/ADM.0000000000000668
http://www.ncbi.nlm.nih.gov/pubmed/32511109?tool=bestpractice.com
However, due to a lack of high-quality trial data, gabapentin, carbamazepine, and valproic acid are not routinely used in practice for AWS management.[106]Prince V, Turpin KR. Treatment of alcohol withdrawal syndrome with carbamazepine, gabapentin, and nitrous oxide. Am J Health Syst Pharm. 2008 Jun 1;65(11):1039-47.
http://www.ncbi.nlm.nih.gov/pubmed/18499876?tool=bestpractice.com
[107]Andaluz A, DeMoss D, Claassen C, et al. Fixed-dose gabapentin augmentation in the treatment of alcohol withdrawal syndrome: a retrospective, open-label study. Am J Drug Alcohol Abuse. 2020;46(1):49-57.
http://www.ncbi.nlm.nih.gov/pubmed/31490712?tool=bestpractice.com
Although limited, available evidence suggests that a high dose of oral gabapentin may be efficacious in limiting withdrawal symptoms among patients with mild AWS versus placebo, lowering benzodiazepine requirements, and it may be equally efficacious as lorazepam for the treatment of AWS.[108]Anton RF, Latham P, Voronin K, et al. Efficacy of gabapentin for the treatment of acohol use disorder in patients with alcohol withdrawal symptoms: a randomized clinical trial. JAMA Intern Med. 2020 May 1;180(5):728-36.
https://www.doi.org/10.1001/jamainternmed.2020.0249
http://www.ncbi.nlm.nih.gov/pubmed/32150232?tool=bestpractice.com
[109]Levine AR, Carrasquillo L, Mueller J, et al. High-dose gabapentin for the treatment of severe alcohol withdrawal syndrome: a retrospective cohort analysis. Pharmacotherapy. 2019 Sep;39(9):881-8.
http://www.ncbi.nlm.nih.gov/pubmed/31278761?tool=bestpractice.com
[110]Myrick H, Malcolm R, Randall PK, et al. A double-blind trial of gabapentin versus lorazepam in the treatment of alcohol withdrawal. Alcohol Clin Exp Res. 2009 Sep;33(9):1582-8.
http://www.ncbi.nlm.nih.gov/pubmed/19485969?tool=bestpractice.com
Evidence for carbamazepine and valproic acid is even more limited than that for gabapentin.[106]Prince V, Turpin KR. Treatment of alcohol withdrawal syndrome with carbamazepine, gabapentin, and nitrous oxide. Am J Health Syst Pharm. 2008 Jun 1;65(11):1039-47.
http://www.ncbi.nlm.nih.gov/pubmed/18499876?tool=bestpractice.com
[111]Barrons R, Roberts N. The role of carbamazepine and oxcarbazepine in alcohol withdrawal syndrome. J Clin Pharm Ther. 2010 Apr;35(2):153-67.
https://www.doi.org/10.1111/j.1365-2710.2009.01098.x
http://www.ncbi.nlm.nih.gov/pubmed/20456734?tool=bestpractice.com
Ketamine
Data suggest that ketamine may reduce benzodiazepine requirement during alcohol withdrawal treatment.[89]Long D, Long B, Koyfman A. The emergency medicine management of severe alcohol withdrawal. Am J Emerg Med. 2017 Jul;35(7):1005-11.
http://www.ncbi.nlm.nih.gov/pubmed/28188055?tool=bestpractice.com
Further research is warranted.
Baclofen
Baclofen is being studied for use in alcohol withdrawal, but there is insufficient evidence to currently support its use in the clinical setting.[5]American Society of Addiction Medicine. The ASAM clinical practice guideline on alcohol withdrawal management. J Addict Med. 2020 May/Jun;14(3s suppl 1):1-72.
https://www.doi.org/10.1097/ADM.0000000000000668
http://www.ncbi.nlm.nih.gov/pubmed/32511109?tool=bestpractice.com
[112]Liu J, Wang LN. Baclofen for alcohol withdrawal. Cochrane Database Syst Rev. 2019 Nov 6;2019(11):CD008502.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008502.pub6/full
http://www.ncbi.nlm.nih.gov/pubmed/31689723?tool=bestpractice.com