What is the recommended approach 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 (diazepam or chlordiazepoxide) preferred for most patients, while lorazepam should be used for those with liver failure, advanced age, or respiratory compromise. 1, 2, 3

Initial Assessment and Risk Stratification

• Use the CIWA-Ar score to guide treatment intensity: scores >8 indicate moderate AWS requiring pharmacological 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 including anxiolytic withdrawal, anxiety disorders, sepsis, hepatic encephalopathy, and severe pain. 4
• Key risk factors for severe withdrawal include chronic heavy drinking, history of withdrawal seizures, and history of delirium tremens. 5
• Look specifically for autonomic hyperactivity (tachycardia, sweating, hypertension), tremor, nausea/vomiting, hallucinations, altered mental status, and disorientation—these indicate severe withdrawal. 4, 5

Treatment Setting Determination

Admit to inpatient treatment if any of the following are present: 4, 1, 2

• Serious complications (delirium tremens, withdrawal seizures)

• High levels of recent drinking

• History of withdrawal seizures or delirium tremens

• Co-occurring serious medical illness (infection, GI bleeding, pancreatitis, liver failure, renal failure)

• Co-occurring serious psychiatric illness

• Failure of outpatient treatment

• Advanced age with debilitating disease

• Outpatient treatment is appropriate for low-risk patients with mild to moderate symptoms and no complicating factors, and is more cost-effective with similar 6-month abstinence rates. 4, 6

Pharmacological Management

Benzodiazepine Selection

For most patients (without liver disease or respiratory compromise): 1, 2, 3

• Diazepam: 10 mg orally/IV 3-4 times during the first 24 hours, then reduce to 5 mg 3-4 times daily as needed. 7
• Chlordiazepoxide: 25-100 mg orally every 4-6 hours. 4, 2, 3
• Long-acting benzodiazepines provide superior protection against seizures and delirium tremens due to their extended duration of action and self-tapering kinetics. 3, 8

For high-risk patients (switch to lorazepam if any of the following): 4, 1, 2

• Severe AWS

• Advanced age

• Liver failure or hepatic dysfunction

• Respiratory failure

• Obesity

• Recent head trauma

• Other serious medical comorbidities

• Lorazepam dosing: Start at 6-12 mg/day (typically 1-4 mg every 4-8 hours), then taper after symptom resolution. 4, 1, 2

• Lorazepam is safer in hepatic insufficiency because it doesn't rely on hepatic oxidation. 2

Critical Adjunctive Therapy

Thiamine must be administered to ALL patients with alcohol withdrawal: 4, 1, 2

• Dosing: 100-300 mg/day to prevent Wernicke encephalopathy
• Timing: Give thiamine BEFORE any glucose-containing IV fluids to prevent precipitating acute thiamine deficiency. 1, 2
• Duration: Maintain for 2-3 months following resolution of withdrawal symptoms. 4, 2
• For Wernicke encephalopathy treatment: 100-500 mg/day for 12-24 weeks. 4

Alternative and Adjunctive Agents

• Carbamazepine 200 mg every 6-8 hours can be used as an alternative for seizure prevention, though benzodiazepines remain superior. 1, 2, 6
• Haloperidol 0.5-5 mg every 8-12 hours may be used cautiously as adjunctive therapy ONLY for agitation or psychotic symptoms not controlled by benzodiazepines alone. 1, 2
• Avoid beta-blockers as first-line therapy—they increase the risk of hallucinations. 5
• Avoid neuroleptics as monotherapy—they increase seizure risk and have higher mortality rates than benzodiazepines in delirium tremens. 5

Treatment Duration and Tapering

• Taper benzodiazepines following resolution of withdrawal symptoms. 4, 2
• Total treatment duration should not exceed 10-14 days to avoid benzodiazepine dependence. 1, 2
• Use a gradual taper to discontinue; if withdrawal reactions develop, pause the taper or increase to the previous dose level, then decrease more slowly. 7

Supportive Care

• Provide fluids and electrolyte replacement (especially magnesium) as needed based on individual losses. 4, 2
• Create a comfortable, reassuring environment with close personal support. 5
• Monitor vital signs frequently, especially in severe cases. 4

Coordination of Care

• Psychiatric consultation is recommended for comprehensive evaluation, acute AWS management, and long-term abstinence planning. 4, 1, 2
• Coordinate care between addiction specialists and other relevant specialists to facilitate long-term treatment. 1

Critical Medications to AVOID

• Disulfiram and naltrexone should be avoided in patients with alcoholic liver disease due to hepatotoxicity risk. 1, 3
• These medications are not beneficial during acute withdrawal. 5

Common Pitfalls

• Delaying benzodiazepine therapy increases the risk of complications—all seizures in one study occurred before medication administration. 9
• Approximately 56% of patients may respond to supportive care alone, but 72% respond more rapidly with diazepam. 8
• Mild symptoms can be managed with carbamazepine or gabapentin, but moderate to severe symptoms require benzodiazepines. 6
• Monitor discharged patients daily for up to 5 days after their last drink, as the 1-week ED return rate approaches 25%. 6, 9