What is the recommended protocol for managing alcohol withdrawal symptoms in a patient using the Clinical Institute Withdrawal Assessment (CIWA) scale?

CIWA Protocol for Alcohol Withdrawal Management

Assessment and Scoring

Use the CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol-Revised) scale to assess withdrawal severity every 4-6 hours initially, then adjust frequency based on symptom stability. 1

• CIWA-Ar score >8 indicates moderate alcohol withdrawal syndrome requiring treatment 1
• CIWA-Ar score ≥15 indicates severe alcohol withdrawal syndrome requiring aggressive treatment 1
• Patients scoring >15 have a 3.72-fold increased risk of severe withdrawal complications if untreated 2
• Scores >10 at admission predict 46.6% risk of delirium tremens versus 2.8% in lower scores 3

Critical caveat: The CIWA-Ar should not be used for diagnosis of alcohol withdrawal syndrome, as high scores can occur in other conditions—use it only for treatment guidance once withdrawal is confirmed 1

Immediate Pre-Treatment Requirements

Administer thiamine 100-500 mg IV immediately BEFORE any glucose-containing fluids or benzodiazepines 4

• This prevents precipitating acute Wernicke encephalopathy 4
• Continue thiamine 100-300 mg/day throughout withdrawal and for 2-3 months after resolution 4
• Thiamine deficiency is present in 30-80% of alcohol-dependent patients 5

Symptom-Triggered Benzodiazepine Protocol

For Patients WITHOUT Hepatic Dysfunction

Diazepam (long-acting benzodiazepine—preferred for seizure protection): 1

• Initial dose: 10 mg orally 6
• Repeat dosing: 5-10 mg every 4-6 hours based on CIWA-Ar scores 6
• Maximum 40 mg in first 24 hours 6
• Give additional doses when CIWA-Ar score ≥8 1
• Long-acting agents provide superior protection against seizures and delirium tremens 4

Alternative: Chlordiazepoxide 4

• Initial: 50-100 mg orally 4
• Repeat: 25-100 mg every 4-6 hours as needed 4
• Maximum 300 mg in first 24 hours 4

For Patients WITH Hepatic Dysfunction, Advanced Age, Respiratory Compromise, or Obesity

Switch to lorazepam (intermediate-acting): 1

• Dosing: 1-4 mg every 4-8 hours (total 6-12 mg/day) 1
• Safer pharmacokinetics due to direct glucuronidation without active metabolites 1
• Despite widespread belief, superiority of short-acting agents in liver disease lacks controlled trial validation, but lorazepam remains preferred to avoid dose-stacking 5

Monitoring Protocol

Assess vital signs before each benzodiazepine dose for autonomic instability: 4

• Tachycardia (heart rate >100 bpm)
• Hypertension (systolic BP >140 mmHg)
• Fever (temperature >38°C)
• Diaphoresis

Reassess CIWA-Ar score every 4-6 hours during active withdrawal 1

• If score remains <8 for 24 hours, monitoring can be reduced 4
• Continue daily monitoring for up to 5 days after last drink 4

Treatment Duration and Tapering

Do not continue benzodiazepines beyond 10-14 days due to abuse potential 4, 1

• Begin tapering long-acting benzodiazepines by 96 hours if symptoms improving 4
• Over 70% of cirrhotic patients may not require benzodiazepines at all—treat only when symptoms present 5
• Do not discontinue prematurely based on day of admission alone—treat until complete symptom resolution 5

Management of Severe Withdrawal (CIWA-Ar ≥15 or Altered Consciousness)

For severe withdrawal with altered consciousness, start IV diazepam 10 mg initially, then 5-10 mg every 3-4 hours 4

For delirium tremens refractory to adequate benzodiazepines, add haloperidol as adjunct only—never as monotherapy 5

• Antipsychotics alone lower seizure threshold and worsen outcomes 5

Critical Medications to AVOID

Do not use anticonvulsants (phenytoin, valproate) for alcohol withdrawal seizures 5

• These are ineffective for withdrawal seizures and may worsen outcomes 5
• Benzodiazepines are the only proven treatment to prevent seizures 4

Avoid naltrexone in patients with alcoholic liver disease due to hepatotoxicity 4

Essential Supportive Care

Fluid and electrolyte replacement with specific attention to: 4

• Magnesium supplementation (commonly depleted in chronic alcohol use) 4
• Evaluate for dehydration, hypokalemia, hypomagnesemia 4

Screen for dangerous complications: 4

• Infection (pneumonia, spontaneous bacterial peritonitis in cirrhotics) 5
• Gastrointestinal bleeding 5
• Pancreatitis 5
• Hepatic encephalopathy 4
• Renal failure 4

Inpatient vs Outpatient Decision

Admit to hospital if any of the following: 4

• CIWA-Ar score ≥15 or significant withdrawal symptoms with vomiting and tremor 4
• History of withdrawal seizures or delirium tremens 4
• Co-occurring serious medical illness (liver disease, infection, pancreatitis) 4
• Co-occurring serious psychiatric illness 4
• Failure of outpatient treatment 4
• Inadequate social support 5

Outpatient treatment appropriate for: 4

• Mild to moderate withdrawal (CIWA-Ar <15) 1
• No history of complicated withdrawal 4
• Adequate social support 5
• Requires daily physician visits for 3-5 days after last drink 4

Post-Acute Management (Mandatory)

Psychiatric consultation is mandatory after stabilization for: 4

• Evaluation of alcohol use disorder severity 4
• Long-term abstinence planning 4
• Consideration of relapse prevention medications 4

Offer pharmacotherapy for relapse prevention: 5

• Acamprosate (first-line) 5
• Naltrexone (if no severe liver disease) 5
• Disulfiram 5
• Baclofen up to 80 mg/day (safe in liver disease) 5

Common Pitfalls to Avoid

• Never administer glucose-containing IV fluids before thiamine—this precipitates Wernicke encephalopathy 4
• Do not use CIWA-Ar for diagnosis—only for treatment guidance 1
• Do not assume all cirrhotic patients need benzodiazepines—over 70% may not require treatment 5
• Do not continue benzodiazepines beyond 10-14 days 4
• Do not use anticonvulsants for withdrawal seizures 5
• Do not use antipsychotics as monotherapy 5