What is the management of alcohol withdrawal syndrome?

From the Guidelines

Benzodiazepines are the first-line treatment for alcohol withdrawal, with lorazepam being a preferred option, especially in patients with liver disease, due to its shorter half-life and lack of active metabolites 1.

Management of Alcohol Withdrawal

The management of alcohol withdrawal requires a systematic approach focusing on symptom control and prevention of complications.

• Benzodiazepines, such as lorazepam (1-4mg every 1-4 hours), are the preferred treatment option for alcohol withdrawal, as they are effective in reducing withdrawal symptoms and preventing seizures and delirium tremens 1.
• A symptom-triggered approach using the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale helps tailor medication dosing to symptom severity, with scores above 8-10 typically indicating the need for medication 1.
• Thiamine (100mg IV or IM for 3-5 days, then oral) should be administered before glucose to prevent Wernicke's encephalopathy, as thiamine deficiency is common in alcohol-dependent individuals 1.
• Fluid repletion with normal saline and correction of electrolyte abnormalities, particularly magnesium and potassium, are essential in managing alcohol withdrawal 1.
• Close monitoring of vital signs and withdrawal symptoms is crucial, with severe cases requiring ICU admission 1.
• After acute withdrawal management, patients should be referred to addiction treatment programs to address the underlying alcohol use disorder and prevent future withdrawal episodes 1.

Key Considerations

• The presence of decompensated liver disease should encourage prioritization of a personalized prescription that is symptom-adapted and favors short-acting drugs, such as lorazepam or oxazepam 1.
• Regular monitoring is necessary to guide dosage adjustment and ensure that there is no seizure, and can be stopped after 24 hours if no specific signs appear 1.
• Antipsychotics like haloperidol may help manage agitation but should not be used alone as they don't prevent seizures 1.
• Phenobarbital (65-130mg IV/IM) can be used as a second-line agent for benzodiazepine-resistant cases [@Example@].

From the FDA Drug Label

DOSAGE AND ADMINISTRATION: ... Symptomatic Relief in Acute Alcohol Withdrawal. 10 mg, 3 or 4 times during the first 24 hours, reducing to 5 mg, 3 or 4 times daily as needed INDICATIONS: ... In acute alcohol withdrawal, diazepam may be useful in the symptomatic relief of acute agitation, tremor, impending or acute delirium tremens and hallucinosis DOSAGE AND ADMINISTRATION: ... For the relief of withdrawal symptoms of acute alcoholism, the parenteral form* is usually used initially. If the drug is administered orally, the suggested initial dose is 50 to 100 mg, to be followed by repeated doses as needed until agitation is controlled — up to 300 mg per day

The management of alcohol withdrawal involves the use of benzodiazepines such as diazepam and chlordiazepoxide.

• Diazepam can be used for symptomatic relief of acute alcohol withdrawal, with a dosage of 10 mg, 3 or 4 times during the first 24 hours, reducing to 5 mg, 3 or 4 times daily as needed 2.
• Chlordiazepoxide can also be used for the relief of withdrawal symptoms of acute alcoholism, with an initial oral dose of 50 to 100 mg, followed by repeated doses as needed until agitation is controlled — up to 300 mg per day 3. Key points to consider in the management of alcohol withdrawal include:
• Individualized dosage: The dosage of benzodiazepines should be individualized for maximum beneficial effect 2.
• Gradual taper: To reduce the risk of withdrawal reactions, a gradual taper should be used to discontinue benzodiazepines or reduce the dosage 2.

From the Research

Management of Alcohol Withdrawal

• The standard of care for management of alcohol withdrawal is symptom-triggered treatment using the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) 4, 5.
• The CIWA-Ar is a 10-question scale that assesses the presence and severity of withdrawal symptoms, but it can be time-consuming and cumbersome to use 6.
• A shorter and more objective method to assess alcohol withdrawal symptoms is the Brief Alcohol Withdrawal Scale (BAWS), a 5-item scale that was developed and implemented in an inpatient unit dedicated to treating substance withdrawal 6.
• The BAWS was compared with the CIWA-Ar and was found to have a sensitivity of 85.3% and specificity of 65.8% in predicting CIWA-Ar scores ≥8 6.
• The use of the CIWA-Ar protocol in a general hospital setting requires mechanisms to ensure assessment of validated alcohol withdrawal risk factors, exclusion of patients who cannot communicate, and continuity of care during transitions 7.
• Benzodiazepines have the best evidence base in the treatment of alcohol withdrawal, followed by anticonvulsants 5.
• Clinical management of alcohol withdrawal may involve symptom-monitored loading for severe withdrawals, where an initial dose is guided by risk factors for complicated withdrawals and further dosing may be guided by withdrawal severity 5.
• Supportive care and use of vitamins is also an important aspect of managing alcohol withdrawal 5.

Assessment Tools

• The CIWA-Ar is a widely used instrument for assessing alcohol withdrawal syndrome, but it has pitfalls in patients with medical comorbidities 5.
• The BAWS is a shorter and more objective method to assess alcohol withdrawal symptoms, but its use in other settings, particularly with patients with concurrent medical illnesses or more severe withdrawal, needs to be explored further 6.
• The modified and translated Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-A) has been found to be a valid and reliable instrument for assessing alcohol withdrawal syndrome 8.