Diazepam Dosing for Alcohol Withdrawal with CIWA-Ar Score of 15
For this 30-year-old female with a CIWA-Ar score of 15 (indicating severe withdrawal), administer diazepam 10 mg orally immediately, then repeat 10 mg every 1-2 hours until her CIWA-Ar score drops to ≤5 or she shows signs of mild sedation. 1, 2
Initial Loading Dose Strategy
Start with 10 mg diazepam orally as the first dose for this patient with severe withdrawal (CIWA-Ar = 15), as recommended by the FDA label for acute alcohol withdrawal 1
Repeat 10 mg every 1-2 hours until the patient becomes asymptomatic or shows mild sedation, using the loading dose technique that takes advantage of diazepam's long half-life for kinetic tapering 2
Most patients respond within 6-7 hours with a median of three 20-mg doses (or six 10-mg doses) required to achieve symptom control 2
CIWA-Ar scores ≥15 indicate severe withdrawal requiring aggressive benzodiazepine dosing, as this threshold signals high risk for progression to seizures and delirium tremens 3, 4
Critical Pre-Treatment Requirements
Administer thiamine 100-500 mg IV immediately BEFORE any glucose-containing fluids to prevent precipitating acute Wernicke encephalopathy—this is mandatory for every patient in alcohol withdrawal 3, 4
Assess vital signs before each dose for autonomic instability including tachycardia, hypertension, fever, and sweating 3
Dosing Algorithm Based on Response
If the patient remains symptomatic after 6 doses (60 mg total), continue giving 10-20 mg every 1-2 hours until clinical improvement occurs 2
There is no absolute maximum dose—titrate aggressively to control symptoms, as benzodiazepines are the only proven treatment to prevent seizures and delirium tremens 3, 4
Once CIWA-Ar drops to ≤5, stop loading doses and transition to maintenance dosing of 5 mg three to four times daily as needed 1
Why Diazepam is Appropriate for This Patient
Long-acting benzodiazepines like diazepam provide superior protection against seizures and delirium tremens compared to shorter-acting agents 3, 4
Diazepam's long half-life provides automatic kinetic tapering after loading, reducing the need for complex dosing schedules 2
This 30-year-old healthy female has no contraindications to diazepam (no hepatic dysfunction, not elderly, no respiratory compromise) 3
Monitoring Requirements During Loading
Reassess CIWA-Ar score before each dose to guide continued dosing intensity 3
Monitor for respiratory depression, especially if combining with other sedatives, though this is rare with benzodiazepine monotherapy 5
Watch for oversedation—mild sedation is the endpoint, not deep sedation 2
Monitor for dangerous complications: dehydration, electrolyte imbalance (especially magnesium), infection, and hepatic encephalopathy 3, 4
Essential Adjunctive Treatment
Continue thiamine 100-300 mg/day throughout treatment and for 2-3 months after withdrawal resolution 3, 4
Replace magnesium, as it is commonly depleted in chronic alcohol use and essential for symptom control 3
Ensure adequate hydration and electrolyte replacement during the withdrawal period 3
Common Pitfalls to Avoid
Do NOT underdose—a CIWA-Ar of 15 represents severe withdrawal requiring aggressive treatment; inadequate dosing increases risk of seizures and delirium tremens 3, 2
Do NOT give glucose before thiamine—this can precipitate acute Wernicke encephalopathy 3, 4
Do NOT continue benzodiazepines beyond 10-14 days due to abuse potential; taper after symptom control is achieved 3
Do NOT use anticonvulsants for seizure prophylaxis—benzodiazepines are required and are the only proven preventive therapy 3, 4
Duration and Tapering
After achieving symptom control (CIWA-Ar ≤5), reduce to 5 mg three to four times daily as needed for ongoing symptoms 1
Begin tapering after 24-48 hours of stability, gradually reducing the dose over the next 7-10 days 1
Total benzodiazepine treatment should not exceed 10-14 days to minimize dependence risk 3