Pharmacological Approaches to Preventing Seizures

Systematic reviews indicate that benzodiazepines substantially reduce the risk of alcohol withdrawal seizures, and the risk of recurrent (further) seizures in a withdrawal episode.

Benzodiazepines with rapid onset (such as diazepam, lorazepam) are recommended. The long duration of diazepam is generally preferred in most cases; however, a short-acting benzodiazepine (such as lorazepam, midazolam) may be preferred where the diagnosis is unclear (for example, possible head injury), or due to severe hepatic failure.

Carbamazepine effectively prevents alcohol withdrawal seizures, but is not effective in preventing recurrent (further) seizures in a withdrawal episode.

There appears to be no advantage in adding anticonvulsants to benzodiazepines for preventing alcohol withdrawal seizures. Phenytoin and valproate do not effectively prevent the onset of alcohol withdrawal seizures and are not recommended. The role of other anticonvulsants (such as gabapentin, topiramate) is yet to be demonstrated, and while their GABAergic actions suggest they may be useful, they are not recommended at this stage.

Prevention of seizures in patients undergoing alcohol withdrawal is as follows:

• In patients with no prior seizure history and not in severe alcohol withdrawal: a symptom-triggered or fixed schedule diazepam regimen is recommended (see ‘Medications for managing alcohol withdrawal’ above for discussion of regimens).
• In patients with prior seizure history, or in severe alcohol withdrawal: diazepam loading is recommended (20 mg every 2 hours until 60–80 mg or patient lightly sedated), and reducing doses on subsequent days.