What is the appropriate protocol for managing alcohol withdrawal in an adult chronic heavy drinker who is now abstinent, using a CIWA‑Ar‑guided symptom‑triggered benzodiazepine regimen, thiamine, electrolyte replacement, and close vital‑sign monitoring?

Management of Alcohol Withdrawal in Adult Chronic Heavy Drinkers

Use a CIWA-Ar-guided symptom-triggered benzodiazepine regimen with long-acting agents (diazepam or chlordiazepoxide) as first-line therapy, administer thiamine 100-500 mg IV before any glucose-containing fluids, replace electrolytes (especially magnesium), and monitor vital signs continuously during the first 24-48 hours. 1

Immediate Assessment and Thiamine Administration

Administer thiamine 100-500 mg intravenously immediately upon presentation and before any glucose-containing fluids to prevent precipitating acute Wernicke encephalopathy. 1, 2 This is mandatory for every patient undergoing alcohol withdrawal management. Continue thiamine 100-300 mg/day orally throughout withdrawal and for 2-3 months after symptom resolution. 1

Assess vital signs for autonomic instability including tachycardia (heart rate >100), hypertension (systolic BP >140), fever (temperature >37.5°C), and diaphoresis. 1 Evaluate for dangerous complications: dehydration, electrolyte imbalance (particularly magnesium and potassium), infection, gastrointestinal bleeding, pancreatitis, hepatic encephalopathy, and renal failure. 1

CIWA-Ar-Guided Symptom-Triggered Benzodiazepine Protocol

Use the CIWA-Ar scale to quantify withdrawal severity; initiate benzodiazepine therapy when the score reaches ≥8, and intensify treatment when the score is ≥15. 1 The CIWA-Ar assesses 10 items: tremor, sweating, anxiety, agitation, tactile/auditory/visual disturbances, headache, orientation, and nausea/vomiting. 1

Symptom-triggered dosing based on repeated CIWA-Ar assessments is superior to fixed-schedule dosing because it reduces total benzodiazepine requirements, lowers 90-day readmission rates, and prolongs time to first readmission. 3 Although symptom-triggered dosing may result in slightly longer initial hospital stays (3.9 vs 2.2 days), it is more cost-effective and associated with reduced relapse rates. 3

Benzodiazepine Selection and Dosing

Long-acting benzodiazepines (diazepam or chlordiazepoxide) are preferred for most patients because they provide superior protection against withdrawal seizures and delirium tremens. 1, 2

For diazepam: Start with 10 mg orally or IV, then administer 5-10 mg every 3-4 hours based on CIWA-Ar scores and clinical response. 1 For severe withdrawal with altered consciousness, use IV diazepam 10 mg initially. 1

For chlordiazepoxide: Initiate with 50-100 mg orally as a loading dose, followed by 25-100 mg every 4-6 hours based on withdrawal severity, with a maximum of 300 mg in the first 24 hours. 1

When to Switch to Short-Acting Benzodiazepines

Switch to lorazepam 6-12 mg/day or oxazepam if the patient has hepatic dysfunction, advanced age (>65 years), respiratory compromise, recent head trauma, or obesity. 1, 2 Short-acting agents avoid drug accumulation and "dose-stacking" in these high-risk populations. 1

Electrolyte Replacement

Replace magnesium aggressively, as it is commonly depleted in chronic alcohol use and contributes to withdrawal severity. 1 Correct hypokalemia, hypophosphatemia, and hyponatremia as identified on laboratory testing. 1 Ensure adequate hydration with careful attention to fluid balance. 1

Vital Sign Monitoring Protocol

Monitor vital signs continuously for the first 24 hours, even in patients without overt symptoms, to detect autonomic instability early. 4 After 24 hours, if no specific withdrawal signs appear, monitoring frequency can be reduced. 1 Continue close observation through days 3-5 when withdrawal symptoms typically peak. 1

Assess CIWA-Ar scores every 1-2 hours during active withdrawal (scores ≥8) and every 4-6 hours once symptoms are controlled (scores <8). 1, 2

Benzodiazepine Tapering

Begin tapering long-acting benzodiazepines after approximately 96 hours (day 4) when acute withdrawal symptoms are improving. 1 Reduce the daily dose by approximately 25% every 2-3 days. 1 For short-acting agents, decrease the daily dose by 10-25% every 2-4 days after initial symptom control. 1

Limit total benzodiazepine therapy to a maximum of 10-14 days to avoid iatrogenic dependence. 1, 2 Complete discontinuation must be achieved by day 14. 1

During dose reductions, monitor for rebound anxiety, tremor, autonomic instability (tachycardia, hypertension, sweating), new-onset seizures, or altered mental status. 1

Adjunctive Therapies (When Benzodiazepines Are Insufficient)

Antipsychotic agents (e.g., haloperidol) may be added only as adjuncts to adequate benzodiazepine regimens in severe withdrawal-related delirium with persistent agitation; they must never be used as monotherapy. 1 Evidence for antipsychotic efficacy in alcohol withdrawal is low-quality. 1

Beta-blockers (e.g., propranolol IV) can be added to control persistent tachycardia and hypertension despite adequate benzodiazepines, but they must never be used as monotherapy because they do not prevent seizures or delirium tremens. 1

Barbiturates (e.g., phenobarbital) or propofol can be second-line for sedation when benzodiazepines are ineffective in severe withdrawal. 5, 6

Medications to Avoid

Do not use anticonvulsants (carbamazepine, valproate, phenytoin) for alcohol withdrawal seizure prophylaxis; benzodiazepines are the only proven therapy that prevents withdrawal seizures. 1 Carbamazepine may be used only as a benzodiazepine-sparing adjunct in patients with severe hepatic impairment or benzodiazepine abuse history, but never as monotherapy and never when CIWA-Ar ≥15. 1

Indications for Inpatient Management

Admit patients with: 1, 2

• Significant withdrawal symptoms (CIWA-Ar ≥8 with vomiting and tremor)
• History of withdrawal seizures or delirium tremens
• Co-occurring serious medical illness (liver disease, infection, pancreatitis, ARDS)
• Concurrent psychiatric illness or active suicide risk
• Failure of prior outpatient treatment
• Insufficient social support or inability to attend daily monitoring
• High levels of recent drinking (>80 g/day for ≥10 years)

Post-Acute Management and Relapse Prevention

After withdrawal stabilization, psychiatric consultation is mandatory for evaluation of alcohol use disorder severity, ongoing treatment planning, and long-term abstinence strategies. 1, 2 This should occur before the benzodiazepine taper is completed. 1

Initiate evidence-based relapse-prevention pharmacotherapy after detoxification is complete: 1, 2

• Acamprosate (≈2 g/day for patients ≥60 kg) is safe in liver disease and reduces craving
• Baclofen (up to 80 mg/day) is the only medication proven safe in cirrhotic patients
• Naltrexone is contraindicated in alcoholic liver disease due to hepatotoxicity risk
• Disulfiram can be useful if administration is monitored
• Topiramate may be considered for relapse prevention

Encourage engagement with mutual-help groups such as Alcoholics Anonymous to sustain recovery. 1

Critical Pitfalls to Avoid

Never administer glucose-containing IV fluids before thiamine, as this precipitates acute Wernicke encephalopathy. 1, 2

Never use fixed-schedule prophylactic benzodiazepines in cirrhotic patients; over 70% may not require benzodiazepines at all—use symptom-triggered dosing only. 1

Never continue benzodiazepines beyond 10-14 days for alcohol withdrawal, as this creates iatrogenic dependence requiring months-long specialist-managed taper. 1

Never discontinue benzodiazepines abruptly, even after short courses, because rebound withdrawal can occur. 1

Never use antipsychotics, beta-blockers, or anticonvulsants as monotherapy; benzodiazepines are mandatory first-line therapy. 1