Management of Alcohol Withdrawal Syndrome
Benzodiazepines are the gold standard first-line treatment for alcohol withdrawal, with long-acting agents like diazepam (5-10 mg every 6-8 hours) or chlordiazepoxide (25-100 mg every 4-6 hours) preferred for most patients to prevent seizures and delirium tremens. 1, 2
Initial Assessment and Risk Stratification
- 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
- Important caveat: The CIWA protocol should NOT be used for diagnosis of AWS, as high scores can occur in other conditions like anxiolytic withdrawal, anxiety disorder, sepsis, hepatic encephalopathy, and severe pain 3, 4
- Carefully evaluate for comorbidities including dehydration, electrolyte imbalance, renal failure, head trauma, infection, GI bleeding, pancreatitis, and liver failure with frequent vital sign monitoring 3
Pharmacological Management Algorithm
Step 1: Choose the Appropriate Benzodiazepine
For most patients (without liver disease or respiratory compromise):
- Diazepam 5-10 mg every 6-8 hours (oral, IV, or IM) 2
- OR Chlordiazepoxide 25-100 mg every 4-6 hours (oral) 4, 2
- These long-acting agents provide better protection against seizures and delirium due to their longer duration of action 2
For high-risk patients (advanced age, liver failure, respiratory failure, obesity, or recent head trauma):
- Switch to Lorazepam 1-4 mg every 4-8 hours (typically 6-12 mg/day total) 1, 4, 2
- Lorazepam is safer in hepatic insufficiency as it doesn't rely on hepatic oxidation 4
- Taper following resolution of withdrawal symptoms 3, 4
Step 2: Essential Adjunctive Therapy
- Thiamine 100-300 mg/day must be given to ALL patients to prevent Wernicke encephalopathy 3, 1, 4
- Critical: Administer thiamine BEFORE any glucose-containing IV fluids to prevent precipitating acute thiamine deficiency 1, 4
- Continue thiamine for 2-3 months following resolution of withdrawal symptoms 3, 4
Step 3: Additional Agents for Refractory Cases
For seizure prevention (alternative to benzodiazepines):
For agitation or psychotic symptoms not controlled by benzodiazepines alone:
Treatment Duration and Tapering
- Taper benzodiazepines following resolution of withdrawal symptoms 3, 4
- Total treatment duration should NOT exceed 10-14 days to avoid benzodiazepine dependence 1, 4
Determining Treatment Setting
Admit for inpatient treatment if:
- Serious complications present (delirium tremens, withdrawal seizures) 3, 1
- High levels of recent drinking 1, 4
- History of withdrawal seizures or delirium tremens 1, 4
- Co-occurring serious medical or psychiatric illness 1, 4
- Failure of outpatient treatment 4
Outpatient treatment may be considered if:
- No serious complications present 3
- Note: Outpatient treatment is more cost-effective with no difference in 6-month abstinence rates, but requires careful patient selection 3
Critical Medications to AVOID
- Disulfiram should be avoided in patients with alcoholic liver disease due to hepatotoxicity risk 1, 2
- Naltrexone is not recommended in patients with alcoholic liver disease due to hepatotoxicity risk 1, 2
Coordination of Care
- Psychiatric consultation is recommended for comprehensive evaluation, acute AWS management, and long-term abstinence planning 3, 1, 4
- Coordinate care between hepatologists and addiction specialists to reduce delays in referral for alcohol dependence treatment 1
Common Pitfalls to Avoid
- Do not use anticonvulsants for alcohol withdrawal seizures—these are rebound phenomena that resolve with benzodiazepines, not genuine seizures requiring anticonvulsants 3
- Symptoms are typically worst at 3-5 days following abrupt cessation of alcohol 3
- The 1-week ED return visit rate approaches 25% for discharged patients, warranting enhanced follow-up and community support 5