Chlordiazepoxide dosing

A single case report describes a man given phenobarbital and chlo-rdiazepoxide who became drowsy, unsteady, and developed slurred speech, nystagmus, poor memory and hallucinations, all of which disappeared once the phenobarbital was withdrawn and the chlordiazepoxide dose reduced from 80 to 60 mg daily. ... 

NICE (2010) Alcohol use disorders sample chlordiazepoxide dosing regimens for use in managing alcohol withdrawal NICE, England. 

Figure 19.4 The activity spectrum of the benzodiazepines. Motor impairment and CNS depression increases with drug dose. (Based on data for chlordiazepoxide (Sternbach, Randall and Gustafson 1964))...

In contrast to chlordiazepoxide and diazepam, lorazepam and oxazepam are not metabolized into active compounds in the liver. Instead, they are excreted by the kidneys following glucuronidation. This is important because many alcohol-dependent patients have compromised liver function. Therefore, when treatment is initiated before the results of blood tests for liver function are known, as is often the case in outpatient clinics, lorazepam and oxazepam may be preferred. Patients with liver disease may still be treated with diazepam and chlordiazepoxide, but at lower doses. This can be accommodated with the loading technique, although hourly dosing with 5 mg of diazepam or 25 mg of chlordiazepoxide may be sufficient. 

Benzodiazepines. Like the barbiturates, benzodiazepines bind to the GABA receptor and are therefore cross-tolerant with alcohol. As a result, they also make suitable replacement medications for alcohol and are widely used for alcohol detoxification. Theoretically, any benzodiazepine can be used to treat alcohol withdrawal. However, short-acting benzodiazepines such as alprazolam (Xanax) are often avoided because breakthrough withdrawal may occur between doses. Intermediate to long-acting benzodiazepines including chlordiazepoxide (Librium), diazepam (Valium), oxazepam (Serax), lorazepam (Ativan), and clonazepam (Klonopin) are more commonly utilized. 

Antacids Chlordiazepoxide Griseofulvin Penicillins (large doses) Vitamin K (large doses)... 

Withdrawal from long-term high-dose use of alcohol or sedative-hypnotic drugs can be life threatening if physical dependence is present. Benzodiazepines, such as chlordiazepoxide Librium) and diazepam Valium), are sometimes used to lessen the intensity of the withdrawal symptoms when alcohol or sedative-hypnotic drug use is discontinued. Benzodiazepines are also employed to help relieve the anxiety and other behavioral symptoms that may occur during rehabilitation. 

It is extremely difficult to state precisely when BZD therapeutic dose dependence was first recognized. In the first 15 years, the BZD field was dominated by intermediate- and long-acting 1,4-BZDs, chiefly chlordiazepoxide and diazepam. A minority of patients were treated continuously with these drugs for longer than 1 year the majority were treated for less than a few months. Most patients were prescribed low therapeutic doses (e.g., 15 to 40 mg chlordiazepoxide/day 10 to 20 mg diazepam/day), not all of which was taken regularly by all patients. 

Long-acting drugs such as chlordiazepoxide and diazepam and, to a lesser extent, phenobarbital are administered in progressively decreasing doses to patients during withdrawal from physiologic dependence on ethanol or other sedative-hypnotics. Parenteral lorazepam is used to suppress the symptoms of delirium tremens. 

Topiramate, another antiepileptic drug, may also be helpful in a dose of 400 mg daily, built up gradually. Small quantities of alcohol may suppress essential tremor but only for a short time. Alprazolam (in doses up to 3 mg daily) or gabapentin (100-2400 mg/d) is helpful in some patients. Others are helped by intramuscular injections of botulinum toxin. Thalamic stimulation by an implanted electrode and stimulator is often worthwhile in advanced cases refractory to pharmacotherapy. Diazepam, chlordiazepoxide, mephenesin, and antiparkinsonism agents have been advocated in the past but are generally worthless. Anecdotal reports of benefit from mirtazapine were not confirmed in a double-blind study, which found no effect on the tremor in most patients. 

Mg levels Action Mg supl Dose 400-800 mg/d + daily—qid w/ full glass of H20 Caution [B, +] Contra Ulcerative colitis, diverticulitis, ileostomy/colostomy, heart block, renal insuff Disp Caps 140 mg tabs 400 mg (OTC) SE D, N Interactions Effects OF chlordiazepoxide, dicumarol, digoxin, indometliacin, INH, quinolones, tetracyclines EMS Monitor ECG for hypokalemia (flattened T waves) OD Unlikely to cause life-threatening Sxs, but may cause D, constipation, cramps, and abd pain symptomatic and supportive... 

Long-acting benzodiazepines (e.g. diazepam and chlordiazepoxide) are used to attenuate alcohol withdrawal symptoms but they also have a dependence potential. To minimise the risk of dependence, administration should be for a limited period only (e.g. chlordiazepoxide 20 mg 4 times daily, gradually reducing to zero over 7-14 days). Mild alcohol withdrawal symptoms may be treated with a lower starting dose, such as 15 mg four times a day. In all cases, the patient should be counselled about the proposed length of the treatment course. Benzodiazepines should not be prescribed if the patient is likely to continue drinking alcohol. 

Chlordiazepoxide, which has a long duration of action (t 2 = 10-25 hours), is useful for the management of alcohol withdrawal and is arguably better tolerated than other benzodiazepines when used for this indication. As with diazepam, loading doses are possible and simplify clinical management. 

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