What is the recommended dosing for Ativan (lorazepam) in managing alcohol withdrawal symptoms as assessed by the Clinical Institute Withdrawal Assessment (CIWA) scale?

Lorazepam Dosing for Alcohol Withdrawal Using CIWA Scale

For alcohol withdrawal management using CIWA assessment, lorazepam should be started at 6-12 mg/day and tapered following resolution of withdrawal symptoms. 1

Initial Dosing Based on Withdrawal Severity

• For patients with moderate withdrawal symptoms (CIWA score >8), initiate pharmacotherapy with lorazepam 2
• Standard initial dosing is 6-12 mg/day of lorazepam for alcohol withdrawal syndrome 1, 3
• For severe withdrawal symptoms, lorazepam 1 mg subcutaneously or intravenously (up to 2 mg maximum) can be administered as needed 1
• Lower doses (0.25-0.5 mg) should be used in older or frail patients, those with COPD, or when co-administered with antipsychotics 1

Dosing Approach

• Symptom-triggered dosing is preferred over fixed tapering dose regimens, as it results in lower total medication amounts (9.5 mg vs 19.9 mg) and shorter treatment duration (47.8 hours vs 146 hours) 4
• CIWA-Ar scale should be used to guide treatment intensity—scores >8 indicate moderate withdrawal requiring treatment, while scores ≥15 indicate severe withdrawal requiring more aggressive management 3
• Lorazepam can be administered orally, sublingually, subcutaneously, or intravenously depending on the clinical situation 1

Special Populations

• Lorazepam is specifically recommended for patients with:
  • Severe alcohol withdrawal syndrome
  • Advanced age
  • Recent head trauma
  • Liver failure
  • Respiratory failure
  • Other serious medical comorbidities
  • Obesity 1, 3
• Lorazepam is preferred over long-acting benzodiazepines like diazepam or chlordiazepoxide in patients with liver dysfunction due to its shorter-acting properties and lower risk of accumulation 2

Monitoring and Duration

• Vital signs and withdrawal symptoms should be closely monitored, especially during the first 72 hours when symptoms are most likely to escalate 5
• Treatment should be tapered following resolution of withdrawal symptoms 1
• Total treatment duration should not exceed 10-14 days to avoid the risk of benzodiazepine dependence 3

Important Adjunctive Measures

• Thiamine (100-300 mg/day) should be administered to all patients with alcohol withdrawal syndrome to prevent Wernicke's encephalopathy 1, 3
• Thiamine should be maintained for 2-3 months following resolution of withdrawal symptoms 1
• Psychiatric consultation is recommended for evaluation, acute management, and long-term abstinence planning 1, 3

Common Pitfalls and Caveats

• The CIWA protocol is helpful for evaluating withdrawal severity but should not be used alone for diagnosis of AWS, as high scores may occur in other conditions (anxiety disorders, sepsis, hepatic encephalopathy) 1
• In patients with severe alcoholic liver disease, benzodiazepines should be used cautiously with monitoring due to risk of excessive sedation or precipitating hepatic encephalopathy 2
• Inpatient treatment is recommended for cases with serious complications such as delirium or seizures 1