From the Guidelines
Patients with alcohol withdrawal can be safely discharged when they demonstrate clinical stability, including a Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) score below 8, no signs of delirium tremens, and normal vital signs, as well as the ability to tolerate oral intake and maintain adequate hydration and nutrition orally, as recommended by the 2018 EASL clinical practice guidelines 1. When considering discharge, several factors should be taken into account, including:
- Clinical stability, as evidenced by a CIWA-Ar score below 8, which indicates a low risk of severe withdrawal symptoms 1
- Resolution of withdrawal symptoms, such as tremors, hyperreflexia, irritability, anxiety, headache, nausea, and vomiting
- Stable vital signs, including heart rate, blood pressure, and temperature
- Ability to tolerate oral intake and maintain adequate hydration and nutrition
- Absence of signs of delirium tremens, seizures, coma, cardiac arrest, and death, which are potential complications of alcohol withdrawal syndrome 1 Prior to discharge, patients should have a clear follow-up plan for alcohol use disorder treatment, which may include:
- Referral to outpatient programs
- Counseling
- Consideration of medications like acamprosate, naltrexone, or disulfiram
- A tapering schedule for benzodiazepines, if needed, typically using longer-acting agents like chlordiazepoxide or diazepam, as recommended by the 2018 EASL clinical practice guidelines 1 Discharge is appropriate when patients have:
- Adequate social support
- Stable housing
- Demonstrate insight into their condition with willingness to engage in ongoing treatment This approach ensures patient safety while transitioning care to the outpatient setting where long-term recovery support can be established, and is in line with the recommendations of the 2018 EASL clinical practice guidelines 1.
From the FDA Drug Label
DOSAGE AND ADMINISTRATION ... Symptomatic Relief in Acute Alcohol Withdrawal. 10 mg, 3 or 4 times during the first 24 hours, reducing to 5 mg, 3 or 4 times daily as needed The basis for discharge of people with alcohol withdrawal is not directly stated in the provided drug label. Key points to consider for discharge decisions include:
- The patient's symptoms have been adequately managed
- The risk of withdrawal reactions has been assessed and mitigated However, the label does not provide explicit criteria for discharge. 2
From the Research
Discharge Criteria for Alcohol Withdrawal
The decision to discharge patients with alcohol withdrawal is based on several factors, including the severity of their symptoms and their response to treatment.
- The Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA-Ar) is a widely used tool to assess the severity of alcohol withdrawal symptoms 3, 4, 5.
- Patients with mild to moderate withdrawal symptoms without additional risk factors for developing severe or complicated withdrawal can be treated as outpatients 4.
- The CIWA-Ar score can be used to determine the need for benzodiazepine treatment, with scores greater than or equal to 10 indicating the need for medication 3.
- Patients who have completed treatment and have shown significant improvement in their symptoms can be considered for discharge 6, 7.
Assessment Tools
Several assessment tools are available to evaluate the severity of alcohol withdrawal symptoms, including:
- The CIWA-Ar scale, which assesses symptoms such as tremors, insomnia, nausea and vomiting, hallucinations, anxiety, and agitation 3, 4, 5.
- The Short Alcohol Withdrawal Scale, which is a shorter version of the CIWA-Ar scale 4.
- The Alcohol Use Disorders Identification Test-Consumption and the Single Alcohol Screening Question instrument, which can be used to assess unhealthy alcohol use in adults 18 years and older 4.
Treatment Options
Treatment options for alcohol withdrawal include:
- Benzodiazepines, which are the first-line therapy for moderate to severe symptoms 6, 4, 7.
- Carbamazepine and gabapentin, which can be used as adjunctive or alternative therapies for mild to moderate symptoms 4, 5.
- Phenobarbital, which has been shown to be an effective alternative to benzodiazepine-based therapy in some studies 7.