A patient with alcohol withdrawal with tremors and autonomic hyperactivity. What is the initial management?

• A. Benzodiazepines (e.g., lorazepam) with supportive care and monitoring.
• B. Disulfiram therapy.
• C. Naltrexone.
• D. Stop all fluids.

Answer: (A)

Blunting brain hyperexcitability is the priority in alcohol withdrawal with tremors and autonomic signs. Benzodiazepines do this by enhancing GABA-A receptor activity, which calms the central nervous system and reduces sympathetic overactivity. This makes them the best initial management, often given with a scheduled taper or symptom-triggered dosing (guided by scales like CIWA-Ar) to quickly control tremors, tachycardia, hypertension, agitation, and risk of seizures or delirium tremens. Alongside the benzo, provide supportive care: IV fluids and electrolyte correction, thiamine supplementation to prevent Wernicke’s, and careful monitoring of vitals. The other options address long-term alcohol use disorder rather than acute withdrawal, and stopping all fluids would be harmful.