Switching from chlordiazepoxide for the management of alcohol withdrawal syndrome

This guidance is in response to the recent DHSC Medicine Supply Notification (March 2026) summarising the shortage of chlordiazepoxide in the UK. It is uncertain how long this shortage will last, and how the market will respond to it.

The aim of this document is to highlight some of questions that teams and organisations will need to consider when deciding if they need to change to an alternative regime for the management of alcohol withdrawal, in either the short or long term.

For guidance on the clinical management of people with alcohol use disorders please consult the UK Clinical guidelines for alcohol treatment (chapters 10-12 and 16). 

What is Alcohol Withdrawal Syndrome (AWS)?

Alcohol acts as a ‘depressant’ on the central nervous system. People who consume alcohol at high levels on a daily (or nearly daily) basis over many months or years are likely to become physically dependent on alcohol. This means that over time, they become increasingly tolerant to alcohol, requiring greater quantities to achieve the same effect. Extended use of alcohol is associated with a down-regulation of the brain’s own γ-aminobutyric acid (GABA) system and compensatory up-regulation of opposing glutamatergic system to act as a balance, activating the central nervous system resulting in withdrawal symptoms (Day, Daly 2022).

Therefore, when people who are physically dependent on alcohol suddenly stop drinking (e.g. when they are admitted to hospital), or they significantly reduce their consumption, they are at risk of alcohol withdrawal. This varies from a mild physical syndrome (e.g. sweating, increased heart rate and blood pressure, feeling nauseous) and psychological symptoms (anxiety, irritation, insomnia) to a life-threatening condition including seizures and hallucinations constituting a medical emergency.

What are the current evidence-based pharmacological treatments for AWS?

The recently published UK Clinical guidelines for alcohol treatment (2026) as well as Recommendations for the British Association for Psychopharmacology (2026) both recommend the use of benzodiazepines as the first-line treatment for AWS. 

The dose, schedule and duration of treatment will be dependent on a clinical risk assessment and ongoing monitoring over a 5 to 14-day period depending on severity of alcohol withdrawal, clinical setting, and staff competencies to ensure the safe management of symptoms and prevention of complications (UK Clinical Guidelines). 

What are Benzodiazepines?

Benzodiazepines are a class of medications which are used to treat a wide range of conditions (BNF). They all act on the GABA receptor complex and therefore stabilise the neurological dysregulation that occurs during alcohol withdrawal syndrome.

However, different benzodiazepines vary in terms of their potency (speed of onset), half-life (the length of time the drug remains active in the body) and whether or not they also have active metabolites, which will extend their duration of action in the body (Baldwin 2022).

The relative risk / benefit ratio for the use of any particular benzodiazepine in the management of AWS is based on several factors:

Individual risk: The severity of alcohol withdrawal; any co-occurring conditions that increase the risk of respiratory depression, or accumulation of the drug (e.g. liver disease, age); interaction with other prescribed medications (e.g. opioids, gabapentinoids etc.) (Traccis et al 2022), or over the counter or illicit substances.

Prescriber risk: Setting (general hospital vs community), staff competencies to monitor use and recognise emerging complications, frequency of monitoring, management of escalating clinical risk, awareness of the potential for diversion of benzodiazepines.

Which Benzodiazepines are used in the management of AWS?

In the UK, Chlordiazepoxide and Diazepam are most commonly used in the acute management of AWS, and there are example protocols in Chapter 10.7 of the UK Clinical guidelines for alcohol treatment (2026).

What do I need to know if our team changes from Chlordiazepoxide to Diazepam?

  • Potency
  • Half-life
  • Active metabolites and potential for accumulation in special groups – see table below
Feature Diazepam Chlordiazepoxide Oxazepam Lorazepam
Current use in UK practice Preferred option for severe withdrawal, seizures; primarily used in general hospital setting First-line for routine medically assisted withdrawal in many UK protocols. Widely used in community, residential and hospital settings Often used in groups with liver impairment, frailty, or the elderly Alternative where IV/IM needed; useful in acute agitation; preferred in liver impairment, frailty or the elderly
Onset of action Rapid Moderate Slow Rapid (IV), Moderate (oral)
Half-life & duration Very long (active metabolites) Long (active metabolites) Short/intermediate (no active metabolites) Short/intermediate (no active metabolites)
Route availability Oral, parenteral, rectal Oral only Oral only Oral, parenteral
Effectiveness Effective for MAAW symptom control and preventing seizures/DTs Effective for MAAW symptom control and preventing seizures/ DTs Effective when used selectively in 'at risk' groups but may be less effective for preventing seizures/DTs Effective for acute control, seizures and agitation
Risk of accumulation High Moderate Low Low
Use in liver disease (UK guidance) Avoid or caution Avoid or caution Some caution Preferred
Dosing approach (UK guidance) Often symptom-triggered or front-loading in severe cases Fixed-dose or symptom-triggered regimens widely used Fixed or symptom-triggered with closer monitoring Often symptom-triggered, particularly IV use
Sedation risk Higher Moderate-high Moderate Moderate
Approximate equivalent doses* 5mg 12.5mg 10mg 0.5mg (500 microgrammes)

* These are only approximations, as different onset of action, half-life and active metabolites will have a significant impact on the relative effect.

At an organisational level, what are the key things to consider?

  • Who in the organisation needs to be involved in any changes to minimise risk to patient safety?
    • Senior Pharmacist
    • Prescribing Committee to review and approve changes
    • Patient Safety Team
    • Communications team
    • ACT clinical lead
    • ACT nurse lead
  • How to ensure there is comprehensive staff awareness of the change and what process can be used to help embed this new prescribing regime (e.g. removing the obsolete drug as a prescribing option).
  • Staff training targeted at different professional groups.
  • Monitoring of any adverse events at either a system or patient level.
  • Unintended consequences of the change.

Please also see our patient Frequently Asked Questions (FAQs) regarding alcohol withdrawal medication.

References and helpful resources