What is the recommended management for alcohol withdrawal?

Management of Alcohol Withdrawal Syndrome

Benzodiazepines are the gold standard treatment for alcohol withdrawal syndrome, with symptom-triggered dosing using validated assessment scales like CIWA-Ar being the most effective approach for most patients. 1

Assessment and Classification

• Use the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale to classify severity:
  • Mild withdrawal: CIWA-Ar score <8
  • Moderate withdrawal: CIWA-Ar score 8-14
  • Severe withdrawal: CIWA-Ar score ≥15 1

Treatment Algorithm

Step 1: Initial Management

• Administer thiamine 100 mg IV before glucose to prevent Wernicke's encephalopathy 1
• Provide IV fluids (normal saline) to correct dehydration and hypotension 1
• Monitor and correct electrolyte abnormalities, particularly potassium, magnesium, and phosphate 1

Step 2: Benzodiazepine Selection and Administration

• First-line treatment: Benzodiazepines 1, 2
  • For patients with normal liver function:
    • Long-acting benzodiazepines preferred (diazepam, chlordiazepoxide) as they provide better protection against seizures and delirium 1, 2
    • Diazepam has the shortest time to peak effect, facilitating rapid symptom control and accurate titration 2
  • For elderly patients or those with hepatic dysfunction:
    • Short or intermediate-acting benzodiazepines (lorazepam, oxazepam) 1

Step 3: Dosing Strategy

• Symptom-triggered approach (preferred method) 1, 3:

  • Assess with CIWA-Ar every 1-2 hours
  • For CIWA-Ar score ≥8:
    • Diazepam 5-10 mg IV for severe agitation 1, 4
    • Lorazepam 2-4 mg IV for severe symptoms or seizures 1
  • Symptom-triggered dosing reduces total medication needed and treatment duration compared to fixed-schedule dosing 3

• Fixed-schedule dosing (alternative for patients at high risk):

  • Chlordiazepoxide 50-100 mg orally every 6 hours, with additional doses as needed based on symptoms, up to 300 mg per day 5
  • Gradually taper dose as symptoms improve 5

Step 4: Treatment Setting Decision

• Inpatient management indicated for:

  • Severe withdrawal symptoms (CIWA-Ar ≥15)
  • History of withdrawal seizures or delirium tremens
  • Significant medical or psychiatric comorbidities
  • Inadequate social support 1

• Outpatient management appropriate for:

  • Mild to moderate symptoms (CIWA-Ar <15)
  • No history of severe withdrawal
  • Good social support
  • No serious comorbidities 1, 6
  • Daily physician follow-up until symptoms subside 6

Special Considerations and Pitfalls

Avoid These Common Mistakes:

• Don't use antipsychotics as standalone treatment - they may lower the seizure threshold 1
• Don't use disulfiram in patients with severe liver disease 1
• Don't delay thiamine administration before giving glucose-containing solutions 7
• Don't overlook psychiatric comorbidities such as anxiety disorders, affective disorders, and other addictions 1

Important Clinical Pearls:

• Diazepam and its active metabolite have the longest elimination half-lives, resulting in a smoother withdrawal with lower incidence of breakthrough symptoms 2
• The fear of increased risk of over-sedation with diazepam compared to other benzodiazepines is largely unfounded when administered using a symptom-based approach 2
• Alcohol withdrawal symptoms typically develop within 6-24 hours after the last drink 1
• Withdrawal complications can include seizures and delirium tremens, which can be fatal if untreated 8

Relapse Prevention

After acute withdrawal management:

• Consider medications to prevent relapse:
  • Acamprosate
  • Naltrexone (avoid in alcoholic liver disease)
  • Baclofen 1
• Encourage participation in mutual help groups like Alcoholics Anonymous 1
• Provide ongoing thiamine supplementation 1
• Refer to addiction services for ongoing care 1