Loading Dose Therapy

Loading dose regimens (also called ‘front-loading’) quickly administer high doses of benzodiazepines in the early stages of alcohol withdrawal and are indicated in: 

• patients with a history of severe withdrawal complications (seizures, delirium) 
• patients presenting in severe alcohol withdrawal and/or severe withdrawal complications (delirium, hallucinations, or following an alcohol withdrawal seizure). 

A common diazepam-loading regimen under these circumstances is 10- 20 mg orally every 1- 2 hours (eg 10 mg hourly) until 60–80 mg is reached or the patient is sedated. Medical review should occur if the patient remains agitated after 80 mg or 4 hours. Other causes of agitation should be excluded, and if so, further doses of diazepam may be needed. Specialist advice should be sought if necessary. Doses over 120 mg should only be given after specialist review to confirm diagnosis, exclude complications and consider alternatives. 

The dose of 80 mg diazepam will have significant sedative effects for several days, and this is generally sufficient to prevent severe withdrawal from occurring during the remainder of the withdrawal episode. While no further doses of diazepam may be needed, it is common for further doses of diazepam to be administered over the subsequent 2 to 3 days for symptomatic relief, as either a fixed reducing regimen (for example, 10 mg four times a day on day 2, 10 mg twice a day on day 3, 5 mg twice a day on day 4); or as required (for example, 5 to 10 mg 6 hourly as needed, based on clinical observation or alcohol withdrawal scale scores).