What are the guidelines for managing alcohol withdrawal?

Management of Alcohol Withdrawal Syndrome

Benzodiazepines are the gold standard first-line treatment for alcohol withdrawal syndrome, with long-acting agents like diazepam and chlordiazepoxide preferred for most patients to prevent seizures and delirium tremens. 1, 2, 3

Initial Assessment and Risk Stratification

When evaluating patients for alcohol withdrawal, identify high-risk features that predict severe withdrawal:

• History of withdrawal seizures or delirium tremens 4
• Chronic heavy drinking patterns 4
• Anxiety, agitation, tremor, excessive sweating, altered consciousness, or hallucinations 4

Use the CIWA-Ar score to guide treatment intensity: scores >8 indicate moderate AWS requiring treatment, and scores ≥15 indicate severe AWS requiring aggressive management. 1, 3 However, do not use CIWA alone for diagnosis, as high scores can occur in other conditions. 1, 3

Pharmacological Management

First-Line: Benzodiazepines

For most patients, use long-acting benzodiazepines:

• Diazepam 10 mg orally every 6-8 hours during the first 24 hours, then reduce to 5 mg 3-4 times daily as needed 5
• Chlordiazepoxide 25-100 mg every 4-6 hours orally as an alternative 1, 2, 3

Long-acting agents provide superior protection against seizures and delirium tremens due to their extended duration of action and self-tapering kinetics. 2, 3

Special Populations Requiring Short/Intermediate-Acting Benzodiazepines

Switch to lorazepam for patients with:

• Advanced age 1, 2, 3
• Hepatic dysfunction or liver failure 1, 2, 3
• Respiratory failure 1, 2, 3
• Obesity 1, 2
• Recent head trauma 1, 2

Lorazepam dosing: 1-4 mg every 4-8 hours (typically 6-12 mg/day total), then taper after symptom resolution. 1, 3 Lorazepam is safer in liver disease because it doesn't require hepatic oxidation for metabolism. 1, 3

Essential Adjunctive Therapy

Thiamine 100-300 mg/day must be administered to ALL patients with alcohol withdrawal to prevent Wernicke encephalopathy. 1, 2, 3

Critical: Give thiamine BEFORE any glucose-containing IV fluids to prevent precipitating acute thiamine deficiency. 1, 3 Continue thiamine for 2-3 months following resolution of withdrawal symptoms. 1

Alternative and Adjunctive Agents

For patients who cannot tolerate benzodiazepines or require additional seizure prophylaxis:

• Carbamazepine 200 mg every 6-8 hours can serve as an alternative for seizure prevention 1, 2, 3

For agitation or psychotic symptoms not controlled by benzodiazepines alone:

• Haloperidol 0.5-5 mg every 8-12 hours may be used carefully as adjunctive therapy only 1, 2, 3
• Use haloperidol cautiously, as neuroleptics can increase seizure risk 4

Treatment Duration and Tapering

Taper benzodiazepines following resolution of withdrawal symptoms, with total treatment duration not exceeding 10-14 days to avoid benzodiazepine dependence. 1, 3

Treatment Setting Determination

Admit to inpatient treatment for:

• Serious medical complications 1, 2, 3
• High levels of recent drinking 1, 2
• History of withdrawal seizures or delirium tremens 1, 2
• Co-occurring serious medical or psychiatric illness 1, 2, 3
• Failure of outpatient treatment 1, 2, 3

Outpatient withdrawal may be appropriate for low-risk patients without these features. 4

Supportive Care

Provide conservative management including:

• Fluid and electrolyte replacement 1
• Vitamin supplementation (especially thiamine) 1
• Comfortable, reassuring environment 4
• Close monitoring of vital signs 4

Management of Severe or Refractory Withdrawal

For patients not responding to standard benzodiazepine doses:

• Consider protocolized escalation of benzodiazepines rather than symptom-triggered approaches, which may decrease need for mechanical ventilation and ICU length of stay 6
• Propofol is appropriate for benzodiazepine-refractory cases 6
• Phenobarbital may be added to benzodiazepines to reduce mechanical ventilation needs 6

Critical Medications to AVOID

Do NOT use in patients with alcoholic liver disease:

• Disulfiram—risk of hepatotoxicity in severe ALD 7, 2, 3
• Naltrexone—risk of hepatotoxicity, not tested in cirrhosis 7, 2, 3

Avoid betablockers (increase hallucination risk) and clonidine (increases nightmare risk), as their efficacy is poorly documented. 4

Coordination of Care

Psychiatric consultation is recommended for comprehensive evaluation, acute AWS management, and long-term abstinence planning. 1 Coordinate care between hepatologists and addiction specialists to reduce delays in referral for alcohol dependence treatment. 7