How should alcohol withdrawal be assessed and managed, including use of the CIWA‑Ar scale, thiamine supplementation, electrolyte correction, and benzodiazepine therapy?

Alcohol Withdrawal Treatment

Immediate Assessment and Pharmacological Management

Benzodiazepines are the mandatory first-line therapy for alcohol withdrawal, being the only proven treatment that prevents seizures and reduces mortality from delirium tremens. 1

Initial Assessment Using CIWA-Ar Scale

• Use the Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA-Ar) to quantify withdrawal severity, assessing 10 items including tremor, sweating, anxiety, agitation, tactile/auditory/visual disturbances, headache, orientation, and nausea/vomiting. 1
• Initiate benzodiazepine therapy when CIWA-Ar score ≥8, using either fixed-schedule or symptom-triggered dosing based on repeated assessments. 1
• A CIWA-Ar score ≥15 indicates severe withdrawal requiring immediate intervention and is an absolute contraindication to alternative agents as monotherapy. 1, 2
• Symptom-triggered regimens are preferred over fixed-dose schedules to prevent drug accumulation. 3

Benzodiazepine Selection and Dosing

Long-acting benzodiazepines (diazepam, chlordiazepoxide) provide superior protection against seizures and delirium tremens and are recommended for most patients. 1, 3

For patients with normal hepatic function:

• Diazepam: Start with 10 mg IV or orally, followed by 5-10 mg every 3-4 hours as needed for severe withdrawal. 1
• Chlordiazepoxide: Initiate at 50-100 mg orally, followed by 25-100 mg every 4-6 hours as needed, with a maximum of 300 mg in the first 24 hours. 1
• Use loading dose technique: give diazepam every 1-2 hours initially until the patient shows clinical improvement and/or mild sedation; further therapy is rarely needed if long half-life drugs are used. 4

For patients with hepatic impairment, elderly, respiratory compromise, or obesity:

• Switch to lorazepam 6-12 mg/day or oxazepam to avoid drug accumulation and excessive sedation. 1, 3
• Over 70% of cirrhotic patients may not require benzodiazepines at all; use symptom-triggered dosing rather than prophylactic administration. 1, 3

Critical Thiamine Administration

Administer intravenous thiamine 100-500 mg immediately BEFORE any glucose-containing fluids to prevent precipitating acute Wernicke encephalopathy. 1, 3

• This precaution applies to every patient undergoing alcohol withdrawal management. 1
• Continue thiamine 100-300 mg/day orally for 2-3 months following resolution of withdrawal symptoms. 1, 3

Supportive Care and Monitoring

Electrolyte and Fluid Management

• Provide fluid and electrolyte replacement with careful attention to magnesium levels, as magnesium is commonly depleted in chronic alcohol use. 1
• Monitor continuously for autonomic instability including tachycardia, hypertension, fever, and sweating. 1, 3
• Evaluate for dangerous complications: dehydration, electrolyte imbalance, infection, gastrointestinal bleeding, pancreatitis, hepatic encephalopathy, and renal failure. 1

Monitoring Protocol

• For outpatients: Daily physician visits are required for 3-5 days after last drink to monitor vital signs and assess withdrawal symptom severity. 1
• For inpatients: Regular monitoring can be stopped after 24 hours if no specific withdrawal signs appear. 1
• Assess vital signs for autonomic instability before each benzodiazepine dose. 1

Timeline of Withdrawal Symptoms

Understanding the predictable temporal sequence guides treatment intensity:

• 6-24 hours: Mild symptoms begin—tremor, sweating, tachycardia, hypertension, nausea, vomiting, anxiety, agitation, hyperreflexia. 3
• Within 48 hours: Withdrawal seizures typically occur as a rebound phenomenon; do not use anticonvulsants for prophylaxis. 1, 3
• 48-72 hours to day 5: Delirium tremens peaks—altered mental status, disorientation, hallucinations, agitation, severe autonomic hyperactivity. 3
• By 96 hours: Patients should show symptom improvement; begin tapering long-acting benzodiazepines. 1

Inpatient vs. Outpatient Decision

Admit to hospital if:

• Significant withdrawal symptoms (CIWA-Ar ≥8) with vomiting and tremor. 1
• History of withdrawal seizures or delirium tremens. 1
• Co-occurring serious medical illness (liver disease, infection, pancreatitis). 1
• Co-occurring serious psychiatric illness. 1
• Failure of outpatient treatment. 1
• High levels of recent drinking (>80 g/day for ≥10 years). 1
• Insufficient social support. 1

Outpatient treatment is appropriate for:

• Mild to moderate withdrawal (CIWA-Ar <15) without complications. 1
• Adequate social support and ability to attend daily visits. 1
• No history of severe withdrawal complications. 1

Medications to Avoid

• Do not use anticonvulsants (including phenytoin) for alcohol withdrawal seizures, as these are rebound phenomena with lowered seizure threshold, not genuine seizures. 1, 3
• Avoid antipsychotics as monotherapy; they may be added only as adjuncts to adequate benzodiazepine regimens in severe withdrawal-related delirium that has not responded to benzodiazepines. 1
• Avoid carbamazepine as monotherapy for severe withdrawal (CIWA-Ar ≥15); it may only be used as adjunctive therapy or in benzodiazepine-sparing situations. 1
• Avoid naltrexone in patients with alcoholic liver disease due to potential hepatotoxicity. 1
• Phenothiazines, barbiturates, paraldehyde, and antihistamines have no role due to toxicity or lack of efficacy. 4

Duration of Benzodiazepine Therapy

• Do not continue benzodiazepines beyond 10-14 days due to abuse potential. 1
• After initial symptom control, reduce dosage to maintenance levels and taper over time. 1
• Psychoactive medications should be dispensed in limited quantities or under supervised administration to minimize misuse risk. 1

Post-Acute Management and Relapse Prevention

Psychiatric consultation is mandatory after stabilization for evaluation, ongoing treatment planning, and long-term abstinence strategies. 1, 3

Relapse prevention medications to consider after withdrawal completion:

• Acamprosate 1
• Naltrexone (avoid in liver disease) 1
• Disulfiram 1
• Baclofen 1
• Topiramate 1

Additional long-term strategies:

• Encourage engagement with mutual-help groups such as Alcoholics Anonymous to sustain recovery. 1
• Arrange psychiatric evaluation to determine severity of alcohol-use disorder. 1

Common Pitfalls to Avoid

• Never give glucose-containing IV fluids before thiamine, as this can precipitate acute Wernicke encephalopathy. 1, 3
• Do not use benzodiazepines prophylactically in all cirrhotic patients; over 70% may not require them—use symptom-triggered dosing. 1, 3
• Do not use anticonvulsants for withdrawal seizure prophylaxis; benzodiazepines are required. 1, 3
• Failure to recognize early signs of withdrawal can lead to rapid progression to severe complications including seizures, delirium tremens, coma, cardiac arrest, and death. 2
• In patients with hepatic dysfunction, avoid long-acting benzodiazepines due to significant risk of "dose-stacking." 1