What is the first-line treatment for delirium tremens?

• A. Benzodiazepines
• B. Antipsychotics
• C. SSRIs
• D. Opioids

Answer: (A)

Delirium tremens is a life-threatening severe alcohol withdrawal state characterized by marked CNS hyperarousal, autonomic instability, agitation, and delirium. The first-line treatment is benzodiazepines because they directly enhance GABA-A–mediated inhibition in the brain, rapidly dampening the excessive neuronal activity driving agitation, tremors, tachycardia, hypertension, and the risk of seizures. This pharmacologic effect smooths the withdrawal process and provides a safer, controlled decline in symptoms over several days. Using a long-acting benzodiazepine (like diazepam or chlordiazepoxide) helps maintain coverage across the withdrawal period; if liver function is a concern, lorazepam or oxazepam are preferred due to more favorable hepatic metabolism. Dosing is typically guided by a symptom scale (CIWA-Ar) to titrate to adequate control without oversedation. While antipsychotics can be used for agitation when necessary, they do not treat the underlying withdrawal physiology and carry risks; SSRIs do not address acute withdrawal, and opioids have no role in managing alcohol withdrawal. Alongside benzodiazepines, give thiamine to prevent Wernicke’s encephalopathy and provide supportive care with fluids and electrolyte correction.