From the Guidelines
The patient should be treated with benzodiazepine-based detoxification using symptom-triggered lorazepam (6-12 mg/day) and thiamine 100mg IV daily for 3 days then oral, as this approach has been shown to be effective in managing alcohol withdrawal syndrome and preventing seizures and delirium tremens 1.
Patient Presentation
The patient is a 50-year-old male presenting for inpatient alcohol detoxification with a 20-year history of alcohol use disorder. He reports drinking 1 liter of vodka daily for the past 5 years with his last drink 12 hours ago. He describes tremors, sweating, anxiety, and insomnia when attempting to stop drinking. Past medical history includes hypertension and gastritis. He denies other substance use.
Physical Examination and Laboratory Findings
Physical examination reveals tachycardia (HR 110), hypertension (BP 160/95), mild tremor, and diaphoresis. CIWA-Ar score is 18, indicating moderate withdrawal. Laboratory findings show elevated liver enzymes (AST 120, ALT 90), macrocytic anemia (Hgb 11.2, MCV 102), and normal electrolytes.
Assessment and Treatment Plan
The assessment confirms alcohol use disorder, severe, with physiological dependence and moderate withdrawal syndrome.
- The treatment plan includes:
- Benzodiazepine-based detoxification using symptom-triggered lorazepam (6-12 mg/day) based on CIWA-Ar scores >10, tapering over 3-5 days
- Thiamine 100mg IV daily for 3 days then oral
- Folate 1mg daily
- Multivitamin daily
- IV fluids for hydration
- Monitoring includes:
- Vital signs and CIWA-Ar assessments q4h
- Seizure precautions
- Daily laboratory monitoring
- The comprehensive plan also includes:
- Motivational interviewing
- Cognitive-behavioral therapy
- Introduction to 12-step facilitation
- Discharge planning for residential or intensive outpatient treatment
- Consideration of medications for alcohol use disorder (naltrexone, acamprosate, or disulfiram) based on patient factors and preferences, as supported by studies such as 1 and 1.
This approach follows SAM guidelines by addressing both the acute withdrawal management and initiating long-term recovery planning, with a focus on reducing morbidity, mortality, and improving quality of life 1.
From the Research
History and Physical (H&P) for Inpatient Detox
- The patient is a 50-year-old male with a history of alcohol use disorder, presenting for inpatient detoxification.
- The patient's vital signs and physical examination will be monitored closely for signs of withdrawal, such as tremors, agitation, and hallucinations 2.
- A thorough medical history will be taken to identify any underlying medical conditions that may complicate the detoxification process, such as liver disease 2.
Assessment and Treatment Plan
- The patient will be assessed for the severity of alcohol withdrawal using a standardized assessment tool, such as the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) 3.
- The treatment plan will include the use of benzodiazepines, such as diazepam, to manage symptoms of withdrawal and prevent complications, such as seizures and delirium tremens 2, 3.
- The patient will also be evaluated for the presence of co-occurring psychiatric or medical conditions, such as anxiety or depression, and treated accordingly 4, 5.
- The patient's medication regimen will be closely monitored and adjusted as needed to prevent over-sedation or other adverse effects 3, 6.
Medication Management
- Diazepam will be used as the primary benzodiazepine for the treatment of moderate to severe alcohol withdrawal, due to its rapid onset of action and long elimination half-life 3.
- The patient will be closely monitored for signs of benzodiazepine misuse, such as taking more than the prescribed dose or using the medication for longer than intended 5, 6.
- Other medications, such as naltrexone or acamprosate, may be considered for the treatment of alcohol use disorder, depending on the patient's individual needs and medical history 4.