What criteria indicate a patient can be discontinued from an alcohol withdrawal protocol (Alcohol Withdrawal Protocol, AWP)?

From the Guidelines

Patients can be discontinued from an alcohol withdrawal protocol when they have had consecutive low scores on the Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA-Ar) - generally scores below 8-10 for at least 24 hours without requiring medication, as indicated by the most recent guidelines 1. To determine if a patient can be taken off an alcohol withdrawal protocol, assess for resolution of withdrawal symptoms and clinical stability.

Key Criteria for Discontinuation

• Consecutive low scores on the CIWA-Ar (below 8-10) for at least 24 hours without requiring medication
• Stable vital signs, with resolution of tachycardia, hypertension, and tremors
• Ability to tolerate oral intake
• No signs of delirium or seizures
• Improved sleep patterns

Considerations for Benzodiazepine Discontinuation

If benzodiazepines were used for management, they may need to be tapered rather than abruptly discontinued, especially if the patient received high doses for several days, as abrupt cessation can cause significant morbidity and even death 1.

Clinical Judgment and Caution

This careful approach to discontinuation is important because alcohol withdrawal symptoms typically peak at 48-72 hours but can persist for up to 7-10 days, with the risk of serious complications like delirium tremens or withdrawal seizures if treatment is stopped prematurely.

Prioritizing Patient Safety

Given the potential risks associated with alcohol withdrawal and benzodiazepine discontinuation, it is crucial to prioritize patient safety and closely monitor their condition during the tapering process, as recommended by recent guidelines 1.

From the FDA Drug Label

Discontinuation or Dosage Reduction of diazepam To reduce the risk of withdrawal reactions, use a gradual taper to discontinue diazepam or reduce the dosage. If a patient develops withdrawal reactions, consider pausing the taper or increasing the dosage to the previous tapered dosage level Subsequently decrease the dosage more slowly

The criteria to discontinue a patient from an alcohol withdrawal protocol (AWP) using diazepam are not explicitly stated in the provided drug label. However, it can be inferred that a patient can be discontinued when they no longer exhibit symptoms of alcohol withdrawal and the dosage has been successfully tapered down to zero, as indicated by the gradual taper instructions to minimize the risk of withdrawal reactions 2.

• The label does not provide specific symptom-based criteria for discontinuation.
• It emphasizes the importance of a gradual taper to reduce the risk of withdrawal reactions.
• Clinical judgment is required to determine when a patient is ready for discontinuation.

From the Research

Discontinuation Criteria for Alcohol Withdrawal Protocol (AWP)

The decision to discontinue a patient from an Alcohol Withdrawal Protocol (AWP) is based on several criteria, including:

• The patient's withdrawal symptoms have been adequately controlled with benzodiazepines, as measured by scales such as the Glasgow Modified Alcohol Withdrawal Scale (GMAWS) 3 or the 5-item Brief Alcohol Withdrawal Scale (BAWS) 4
• The patient has not experienced any severe withdrawal symptoms, such as delirium tremens, or has not required high doses of benzodiazepines, such as ≥40mg of diazepam administered within one hour 5
• The patient's condition has stabilized, and they are no longer at risk of developing severe withdrawal symptoms
• The patient has been transitioned to a less intensive treatment protocol, such as oral benzodiazepines, and is able to manage their withdrawal symptoms without the need for close monitoring

Key Considerations

When considering discontinuation of a patient from an AWP, healthcare providers should take into account the following factors:

• The patient's individual response to treatment, including their symptoms, medication use, and overall condition
• The risk of relapse or recurrence of withdrawal symptoms, particularly in patients with a history of severe withdrawal or those who have required high doses of benzodiazepines
• The availability of alternative treatment options, such as outpatient detoxification or rehabilitation programs, and the patient's eligibility for these programs
• The need for ongoing monitoring and support to ensure the patient's safe transition off the AWP, as patients who receive front-loaded lorazepam may have an increased incidence of ICU-delirium 6