What is the recommended PRN (pro re nata) medication for agitation in a patient on Clinical Institute Withdrawal Assessment (CIWA)?

PRN Medication for Agitation in Patients on CIWA Protocol

Benzodiazepines, specifically lorazepam, are the recommended PRN medication for agitation in patients on the Clinical Institute Withdrawal Assessment (CIWA) protocol. 1

First-Line Medication Choice

• Lorazepam is considered the most appropriate medication for acute agitation in patients undergoing alcohol withdrawal, with a recommended starting dose of 1 mg PRN 1, 2
• For patients with hepatic dysfunction (common in alcohol-related liver disease), short and intermediate-acting benzodiazepines like lorazepam are safer than long-acting options like diazepam or chlordiazepoxide 1
• Lorazepam can be administered through multiple routes depending on patient cooperation:
  • Oral/sublingual if patient is cooperative
  • Intramuscular or intravenous (up to 2 mg maximum) if patient is uncooperative or severely agitated 2, 3

Dosing Considerations

• Standard dosing for lorazepam is 1 mg PRN, which can be administered as frequently as every hour if needed, though 4-8 hour intervals are often sufficient 2, 3
• For elderly patients, those with respiratory conditions, or severe liver dysfunction, lower doses (0.25-0.5 mg) should be used to prevent excessive sedation 2, 4
• The CIWA-Ar protocol uses a symptom-triggered regimen rather than a fixed dose schedule to prevent medication accumulation 1

Rationale for Benzodiazepine Selection

• Benzodiazepines are considered the "gold standard" for alcohol withdrawal syndrome as they:
  • Reduce withdrawal symptoms
  • Prevent seizures and delirium tremens
  • Provide rapid control of agitation 1
• Lorazepam is particularly advantageous in patients with liver disease due to its shorter half-life and lack of active metabolites compared to long-acting benzodiazepines 1

Alternative Options

• If lorazepam is contraindicated or ineffective, other options include:
  • Haloperidol 0.5-1 mg PRN, though it carries higher risk of extrapyramidal side effects 5, 6
  • Olanzapine 2.5-5 mg PRN (oral or IM), which has shown efficacy in treating agitation with fewer extrapyramidal side effects 3, 5

Important Monitoring Considerations

• Monitor for excessive sedation, especially in patients with compromised liver function 1, 4
• Be aware of potential paradoxical agitation, which occurs in approximately 10% of patients treated with benzodiazepines 3, 4
• Avoid long-term use of benzodiazepines beyond the initial 10-14 days of treatment due to potential for abuse, particularly in patients with alcohol use disorder 1
• Regular assessment of CIWA-Ar scores helps guide medication dosing - scores >8 indicate moderate AWS while scores ≥15 indicate severe AWS requiring more aggressive treatment 1

Special Considerations for Alcohol Withdrawal

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