Is Thorazine (chlorpromazine) safe for managing alcohol withdrawal symptoms assessed by Clinical Institute Withdrawal Assessment (CIWA)?

Thorazine (Chlorpromazine) is Not Recommended for CIWA-Based Alcohol Withdrawal Management

Benzodiazepines, not Thorazine (chlorpromazine), are the gold standard treatment for alcohol withdrawal syndrome assessed by CIWA-Ar. 1

First-Line Treatment Options for Alcohol Withdrawal

• Benzodiazepines are considered the gold standard treatment for alcohol withdrawal syndrome (AWS) due to their efficacy in reducing withdrawal symptoms and preventing seizures and delirium tremens 1
• Long-acting benzodiazepines (e.g., diazepam, chlordiazepoxide) provide better protection against seizures and delirium, while short and intermediate-acting benzodiazepines (e.g., lorazepam, oxazepam) are safer in elderly patients and those with hepatic dysfunction 1
• For patients with liver disease, short-acting benzodiazepines like lorazepam should be used at a dosage of 6-12 mg/day and tapered following resolution of withdrawal symptoms 1

Why Phenothiazines Like Thorazine Are Not Recommended

• Phenothiazines (including Thorazine/chlorpromazine) have no role in the primary treatment of alcohol withdrawal due to their toxicity or lack of efficacy 2
• Phenothiazines lower the seizure threshold and may increase the risk of withdrawal seizures 3
• Phenothiazines do not address the GABA-related mechanisms of alcohol withdrawal that benzodiazepines effectively target 1

Appropriate Use of CIWA-Ar Protocol

• The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) is useful for evaluating AWS severity, with scores >8 indicating moderate AWS and scores ≥15 indicating severe AWS 1
• Symptom-triggered dosing based on CIWA-Ar scores is recommended rather than fixed-dose schedules to prevent medication accumulation 1
• Studies show that symptom-triggered dosing results in less medication being administered while achieving similar reduction in CIWA-Ar scores 4

Special Considerations

• Thiamine supplementation (100-300 mg/day) should be given to all patients with AWS and maintained for 2-3 months following resolution of withdrawal symptoms to prevent Wernicke encephalopathy 1, 3
• In cases where benzodiazepines are insufficient, haloperidol (not chlorpromazine) may be used as an adjunct specifically for controlling hallucinations in patients already treated with benzodiazepines 2
• Phenobarbital has emerged as a potential alternative to benzodiazepines in some settings, with studies showing shorter ICU and hospital stays compared to CIWA-Ar guided benzodiazepine therapy 5

Common Pitfalls to Avoid

• Using phenothiazines like Thorazine as primary treatment for alcohol withdrawal increases seizure risk 3, 2
• Neglecting thiamine supplementation can lead to irreversible Wernicke encephalopathy 3
• Failing to recognize that high CIWA-Ar scores may be seen in conditions similar to AWS, such as anxiolytic withdrawal, anxiety disorder, sepsis, hepatic encephalopathy, and severe pain 1
• Missing underlying psychiatric comorbidities that can emerge or worsen during withdrawal 3

Treatment Algorithm

1. Assess AWS severity using CIWA-Ar scale 1, 6
2. For CIWA-Ar scores >8:
   • Initiate benzodiazepine therapy (diazepam or lorazepam if liver disease present) 1
   • Use symptom-triggered dosing based on CIWA-Ar scores 1, 4
3. Administer thiamine 100-300 mg/day to all patients 1, 3
4. Consider psychiatric consultation for evaluation and long-term abstinence planning 1
5. For hallucinations despite benzodiazepine treatment, consider adding haloperidol (not chlorpromazine) 2