What is the recommended protocol for managing acute alcohol withdrawal, including benzodiazepine dosing, CIWA‑Ar scoring, and alternative agents?

Alcohol Withdrawal Management

Immediate Assessment and Pharmacological Treatment

Benzodiazepines are the mandatory first-line treatment for alcohol withdrawal syndrome, as they are the only proven therapy to prevent seizures and reduce mortality from delirium tremens. 1, 2

Benzodiazepine Selection and Dosing

For most patients without hepatic dysfunction:

• Diazepam 10 mg IV/PO initially, then 5-10 mg every 3-4 hours as needed is the preferred long-acting agent, providing superior seizure protection through smooth withdrawal coverage 1, 3
• Alternatively, chlordiazepoxide 50-100 mg orally initially, followed by 25-100 mg every 4-6 hours (maximum 300 mg in first 24 hours) 1

For patients with hepatic dysfunction, elderly patients, respiratory compromise, or recent head trauma:

• Switch to lorazepam 2-4 mg IV/PO/IM every 4-8 hours due to safer pharmacokinetics and reduced risk of dose-stacking in liver disease 1, 2, 3

Critical dosing principles:

• Titrate to symptoms with no specified dose limit during acute withdrawal 1
• Limit total benzodiazepine treatment duration to 10-14 days maximum to prevent iatrogenic dependence 1, 2

CIWA-Ar Scoring Protocol

The Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA-Ar) is the gold standard tool for quantifying withdrawal severity and guiding treatment decisions. 1

CIWA-Ar scoring thresholds:

• Score ≥8: Initiate benzodiazepine therapy 1
• Score ≥15: Indicates severe withdrawal requiring aggressive treatment and strong consideration for inpatient management 1
• Score <8: Observation with repeat assessments every 8 hours for 48 hours may be appropriate 4

The scale assesses 10 items: tremor, sweating, anxiety, agitation, tactile/auditory/visual disturbances, headache, orientation, and nausea/vomiting 1

Dosing strategies:

• Symptom-triggered dosing (based on repeated CIWA-Ar assessments) reduces total benzodiazepine exposure and treatment duration compared to fixed-schedule dosing 5, 6
• Assess CIWA-Ar before each PRN dose to guide administration 6

Mandatory Thiamine Administration

Thiamine 100-500 mg IV must be administered immediately BEFORE any glucose-containing fluids to prevent precipitating acute Wernicke encephalopathy—this applies to every patient with alcohol withdrawal. 1, 2

Thiamine dosing regimens:

• Prophylactic: 100-300 mg/day orally or IV throughout withdrawal and for 2-3 months after resolution 1, 2
• Therapeutic (for established Wernicke encephalopathy): 100-500 mg/day IV for 12-24 weeks 2

Alternative and Adjunctive Agents

Phenobarbital

Phenobarbital may be considered as an alternative protocol in ICU settings, with evidence showing shorter ICU length of stay (2.4 vs 4.4 days) and reduced need for mechanical ventilation (2% vs 23%) compared to CIWA-Ar-based benzodiazepine protocols. 7

Carbamazepine

Carbamazepine can serve as a benzodiazepine-sparing adjunct in patients with severe hepatic impairment or benzodiazepine abuse history, but MUST NOT be used as monotherapy for severe withdrawal (CIWA-Ar ≥15) or in patients at risk for seizures. 1

Antipsychotics

Haloperidol 0.5-5 mg PO/IM may be added as adjunctive therapy for severe agitation or psychosis refractory to adequate benzodiazepine dosing, but NEVER as monotherapy, as antipsychotics alone lower seizure threshold and worsen outcomes. 2

Dexmedetomidine

Dexmedetomidine serves only as adjunctive therapy for severe, benzodiazepine-refractory cases in ICU settings; it does not prevent seizures or delirium tremens and should never replace benzodiazepines as primary treatment. 1

Anticonvulsants

Do NOT use phenytoin or carbamazepine for seizure prophylaxis after alcohol withdrawal seizures—they are ineffective for this indication and benzodiazepines remain mandatory. 1, 2

Supportive Care and Monitoring

Essential adjunctive measures:

• Fluid and electrolyte replacement with particular attention to magnesium repletion, as magnesium is commonly depleted in chronic alcohol use 1, 2
• Continuous vital sign monitoring for autonomic instability: tachycardia, hypertension, hyperthermia, sweating 1, 2
• Evaluate for dangerous complications: dehydration, infection (pneumonia, spontaneous bacterial peritonitis), gastrointestinal bleeding, pancreatitis, hepatic encephalopathy 1, 2

Inpatient vs. Outpatient Decision Algorithm

Admit to hospital if ANY of the following are present:

• Significant withdrawal symptoms (tremor, vomiting, CIWA-Ar ≥8) 1
• History of withdrawal seizures or delirium tremens 1, 2
• Chronic heavy drinking (>80 g/day for ≥10 years) 1, 2
• Co-occurring serious medical illness (liver disease, infection, cardiovascular disease, pancreatitis) 1, 2
• Co-occurring serious psychiatric illness 1, 2
• Inadequate social support or failure of prior outpatient treatment 1, 2

Outpatient management is appropriate for:

• Mild to moderate withdrawal (CIWA-Ar <15) without complications 1
• Adequate social support with ability to attend daily physician visits for 3-5 days 1
• No history of severe withdrawal complications 1

Post-Acute Management and Relapse Prevention

Psychiatric consultation is mandatory after stabilization for evaluation, ongoing treatment planning, and long-term abstinence strategies. 1, 2

Evidence-based relapse prevention medications (initiate after withdrawal completion):

• Acamprosate (≈2 g/day for patients ≥60 kg): Reduces craving and maintains abstinence; safe in liver disease 2
• Naltrexone (25 mg for 1-3 days, then 50 mg daily): Decreases heavy drinking but CONTRAINDICATED in alcoholic liver disease due to hepatotoxicity 1, 2, 3
• Baclofen (up to 80 mg/day): The only medication with proven safety in cirrhotic patients 1, 2
• Disulfiram (500 mg daily for 1-2 weeks, then 125-500 mg daily): CONTRAINDICATED in severe alcoholic liver disease due to hepatotoxicity 2, 3
• Topiramate: Consider as alternative relapse prevention agent 1

Encourage engagement with mutual-help groups such as Alcoholics Anonymous to sustain recovery. 2

Critical Pitfalls to Avoid

• Never administer glucose-containing IV fluids before thiamine—this can precipitate acute Wernicke encephalopathy 1, 2
• Never use antipsychotics or anticonvulsants as monotherapy for alcohol withdrawal 1, 2
• Never continue benzodiazepines beyond 10-14 days due to abuse potential 1, 2
• Do not assume all cirrhotic patients need benzodiazepines—over 70% may not require pharmacological treatment; dose only when symptoms are present 1, 2
• Do not discontinue benzodiazepines prematurely based on day of admission alone—treat until complete symptom resolution 2
• Dispense psychoactive medications in limited quantities or under supervised administration to minimize misuse risk 1, 2