What is the initial dose of Valium (diazepam) for a patient with a Clinical Institute Withdrawal Assessment (CIWA) score greater than 7?

Diazepam Dosing for CIWA Score >7

For patients with a CIWA score >7, the initial dose of diazepam should be 10 mg IV or PO, with subsequent doses of 5-10 mg every 3-4 hours as needed based on ongoing CIWA assessment. 1

Rationale and Approach

Alcohol withdrawal syndrome requires prompt treatment with benzodiazepines to prevent progression to more severe symptoms including seizures and delirium tremens. Diazepam is preferred for most patients due to its long half-life which provides a natural tapering effect.

Dosing Algorithm:

1. Initial Assessment:

   • CIWA score 8-14 (moderate withdrawal): Diazepam 10 mg PO/IV
   • CIWA score ≥15 (severe withdrawal): Diazepam 10-20 mg PO/IV

2. Maintenance Dosing:

   • Reassess CIWA score every 1-2 hours
   • If CIWA remains >7: Administer 5-10 mg diazepam every 3-4 hours as needed 1
   • If symptoms persist after 2-3 doses: Consider increasing to 10-20 mg per dose

3. Symptom-Triggered Approach:

   • Continue to dose based on CIWA scores rather than fixed schedule
   • This approach has been shown to decrease total benzodiazepine requirements and length of treatment 2

Special Considerations

• Hepatic Dysfunction: Consider using lorazepam 1-4 mg PO/IV/IM every 4-8 hours instead of diazepam as it doesn't require hepatic metabolism 1

• Front-Loading Strategy: For severe withdrawal, a front-loading approach with higher initial doses (20 mg diazepam every 1-2 hours until symptoms improve) may be more effective in preventing complications 3, 4

• Adjunctive Treatments:

  • Thiamine 100-300 mg/day IV or PO to prevent Wernicke encephalopathy
  • Electrolyte replacement (particularly magnesium, potassium, phosphate)
  • Adequate hydration 1

Monitoring

• Continue regular CIWA assessments every 1-2 hours until scores are consistently <8
• Monitor for respiratory depression, especially if combined with other sedatives
• Assess for signs of benzodiazepine toxicity (excessive sedation, confusion, ataxia)

Evidence Strength

High-dose front-loading diazepam protocols have been shown to reduce the need for physical restraints and shorten hospital length of stay compared to lower-dose protocols 4. Both diazepam and lorazepam have demonstrated similar efficacy in managing severe alcohol withdrawal, with lorazepam potentially being more cost-effective 5.

The symptom-triggered approach using CIWA scores has been shown to safely reduce unnecessary benzodiazepine administration in patients at risk for alcohol withdrawal 2.