Chlordiazepoxide Dosing for Alcohol Withdrawal with CIWA Score of 14
For a patient with a CIWA score of 14 indicating moderate alcohol withdrawal, the recommended initial dose of chlordiazepoxide (Librium) is 50-100 mg orally, followed by repeated doses as needed until agitation is controlled, up to 300 mg per day. 1
Initial Dosing Approach
- For moderate alcohol withdrawal (CIWA-Ar score of 14), chlordiazepoxide should be initiated at 50-100 mg orally, with repeated doses as needed until symptoms are controlled 1
- The FDA-approved dosing for alcohol withdrawal symptoms recommends up to 300 mg total daily dose, with subsequent tapering to maintenance levels 1
- Symptom-triggered dosing is preferred over fixed-schedule dosing to prevent both under-treatment and excessive sedation 2
Dosing Schedule Options
- Symptom-triggered approach: Administer 25-100 mg every 4-6 hours based on CIWA-Ar scores, with higher doses for scores >15 2
- Fixed-dose tapering regimen: Start with 50-100 mg every 6 hours on day 1, then gradually decrease over 7-10 days 2
- Standard dosing for chlordiazepoxide in alcohol withdrawal syndrome typically follows a decremental fixed-dose regimen over 9-10 days 2
Special Considerations
- For patients with hepatic dysfunction, lorazepam is safer than chlordiazepoxide as it doesn't rely on hepatic oxidation 2, 3
- Lorazepam has been shown to be non-inferior to chlordiazepoxide in reducing alcohol withdrawal symptoms in comparative studies 3, 4
- Concurrent thiamine supplementation (100-300 mg/day) is essential to prevent Wernicke encephalopathy 5, 2
Monitoring and Adjustment
- Reassess CIWA-Ar scores frequently (every 1-2 hours initially) to guide subsequent dosing 2
- Vital signs should be monitored closely, especially during the first 72 hours when symptoms are most likely to escalate 2
- If the patient receives two bolus doses in an hour without adequate symptom control, consider increasing the dosage 2
Discharge Planning
- Treatment should continue until CIWA-Ar scores are consistently below 8, indicating mild or resolved withdrawal 6
- Ensure the patient has stable vital signs with no tachycardia, hypertension, or fever for at least 24 hours before considering discharge 6
- Verify absence of complications such as seizures, hallucinations, or delirium tremens 6
Common Pitfalls to Avoid
- Underdosing in the initial phase can lead to progression to more severe withdrawal symptoms including seizures and delirium tremens 2
- Prescribing benzodiazepines for longer than necessary (beyond 7-14 days) increases the risk of dependence 6
- Overlooking concurrent substance use disorders that may complicate recovery and treatment response 6