What is the first-line treatment for managing alcohol withdrawal as assessed by the Clinical Institute Withdrawal Assessment (CIWA) scale?

First-Line Treatment for Alcohol Withdrawal Based on CIWA-Ar Assessment

Benzodiazepines are the first-line treatment for alcohol withdrawal syndrome (AWS) as assessed by the CIWA-Ar scale, with long-acting benzodiazepines such as diazepam preferred for most patients. 1

Assessment Using CIWA-Ar

The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) is the standard tool for evaluating withdrawal severity, with scores categorized as:

• <8: Mild withdrawal
• 8-14: Moderate withdrawal
• ≥15: Severe withdrawal 1

Important considerations:

• CIWA-Ar should not be used alone for diagnosis as high scores may also occur in anxiety disorders, sepsis, hepatic encephalopathy, and severe pain 2, 1
• Assessment should include previous withdrawal history, especially seizures and delirium tremens 1

Medication Protocol Based on CIWA-Ar Score

Benzodiazepine Options

1. Long-acting benzodiazepines (preferred for most patients):

   • Diazepam: 5-10 mg PO/IV every 6-8 hours 1, 3
   • Chlordiazepoxide: 25-100 mg PO every 4-6 hours 1

2. Short/intermediate-acting benzodiazepines (for patients with hepatic dysfunction or elderly):

   • Lorazepam: 1-4 mg PO/IV/IM every 4-8 hours 2, 1
   • Oxazepam: 15-30 mg PO every 6-8 hours 1

Dosing Strategy

• Symptom-triggered approach based on CIWA-Ar scoring is superior to fixed-schedule dosing, resulting in lower total medication doses and shorter treatment duration 1
• For acute alcohol withdrawal, diazepam dosing may start at 10 mg, 3-4 times during the first 24 hours, reducing to 5 mg, 3-4 times daily as needed 3

Adjunctive Treatments

1. Thiamine supplementation:

   • 100-300 mg/day for all AWS patients 2, 1
   • Continue for 2-3 months following resolution of withdrawal symptoms 2
   • Administer before any IV glucose to prevent precipitating acute thiamine deficiency 2

2. Electrolyte replacement:

   • Correct magnesium, potassium, and phosphate deficiencies 1
   • Monitor glucose levels 1

3. Adjunctive medications for specific symptoms:

   • Haloperidol (0.5-5 mg PO/IM every 8-12 hours) for agitation or psychotic symptoms not controlled by benzodiazepines 2, 1
   • Note: Antipsychotics should not be used as standalone treatment for AWS 1

Treatment Setting Considerations

• Outpatient management is appropriate for:

  • Mild to moderate withdrawal
  • No history of withdrawal seizures or delirium tremens
  • Adequate social support

• Inpatient treatment is recommended for:

  • Severe withdrawal (CIWA-Ar ≥15)
  • History of withdrawal seizures or delirium tremens
  • Significant medical or psychiatric comorbidities
  • Failed outpatient treatment 2

Special Considerations

• Liver disease: Use lorazepam or oxazepam instead of long-acting benzodiazepines; monitor for oversedation and respiratory depression 1

• Delirium tremens: Typically begins 48-72 hours after last drink; requires inpatient management (often ICU), aggressive benzodiazepine treatment, IV fluids, electrolyte correction, and thiamine supplementation 1

• Alternative scales: Some institutions have developed shorter assessment tools like the Brief Alcohol Withdrawal Scale (BAWS), which has shown good correlation with CIWA-Ar and may be easier to implement 4

Long-Term Management

• Psychiatric consultation for evaluation, treatment, and long-term planning of alcohol abstinence 2
• Consider medications to prevent relapse (acamprosate, naltrexone, disulfiram) 1
• Refer to specialized addiction services and mutual help groups 1

While some research has explored alternative agents like baclofen 5 and clonidine 6, there is currently insufficient evidence to recommend these as first-line treatments for AWS over benzodiazepines.