What is the recommended assessment and treatment protocol for alcohol withdrawal in an adult who has recently reduced or stopped heavy drinking?

Alcohol Withdrawal: Assessment and Treatment Protocol

Immediate Assessment and Risk Stratification

Benzodiazepines are the only proven treatment to prevent seizures and reduce mortality from delirium tremens in alcohol withdrawal, and must be initiated promptly in any patient with significant withdrawal symptoms. 1

Critical Initial Actions (Within Minutes)

• Administer thiamine 100-500 mg IV immediately before any glucose-containing fluids to prevent precipitating acute Wernicke encephalopathy—this is mandatory for every patient with suspected alcohol withdrawal 1, 2
• Check finger-stick glucose and correct hypoglycemia only after thiamine has been given 1
• Assess vital signs for autonomic instability: tachycardia, hypertension, fever, and diaphoresis indicate more severe withdrawal 1, 3

Timeline and Symptom Recognition

• Withdrawal symptoms typically begin 6-24 hours after the last drink, peak at days 3-5, and resolve within one week 1, 4
• Early manifestations (6-24 hours): tremor, sweating, tachycardia, hypertension, anxiety, agitation, nausea/vomiting, and hyperreflexia 1, 3
• Hallucinations occur at 12-24 hours in 2-8% of patients 4
• Seizures develop at 12-48 hours in up to 15% of patients 4
• Delirium tremens emerges 48-72 hours after cessation with confusion, hallucinations, and severe autonomic instability—mortality can reach 50% without treatment 1, 4

Mandatory Inpatient Admission Criteria

Admit to hospital if any of the following are present 1, 2:

• History of withdrawal seizures or delirium tremens
• Significant current withdrawal symptoms (tremor, vomiting, tachycardia)
• Chronic heavy drinking >80 g/day for ≥10 years
• Co-existing serious medical illness (liver disease, infection, pancreatitis, GI bleeding, cardiovascular disease)
• Co-existing serious psychiatric illness or active suicide risk
• Inadequate social support or failure of outpatient treatment
• Recent head trauma, respiratory compromise, or severe malnutrition

Pharmacological Management

First-Line Benzodiazepine Selection

Long-acting benzodiazepines (diazepam or chlordiazepoxide) provide superior protection against seizures and delirium tremens and are preferred for most patients 1, 5:

• Diazepam: 10 mg orally/IV initially, then 5-10 mg every 3-4 hours as needed during the first 24 hours 1, 5
• Chlordiazepoxide: 50-100 mg orally as loading dose, then 25-100 mg every 4-6 hours (maximum 300 mg in first 24 hours) 1, 5

Switch to short-acting benzodiazepines (lorazepam or oxazepam) in the following populations 1, 5:

• Hepatic dysfunction or cirrhosis
• Elderly patients
• Respiratory compromise
• Recent head trauma
• Obesity

Lorazepam dosing: 2-4 mg orally/IV/IM every 4-6 hours, or 6-12 mg/day divided 1, 5

Dosing Strategy

• Use symptom-triggered dosing guided by CIWA-Ar scores (treat when score ≥8) rather than fixed-schedule dosing 1, 5
• Over 70% of cirrhotic patients may not require benzodiazepines at all—dose only when symptoms are present 1, 2
• Limit benzodiazepine therapy to a maximum of 10-14 days to prevent iatrogenic dependence 1, 2
• Begin tapering long-acting benzodiazepines after approximately 96 hours (day 4) by reducing daily dose by 25% every 2-3 days 1

Common Pitfall to Avoid

Never discontinue benzodiazepines prematurely based on day of admission alone—continue treatment until complete symptom resolution, as withdrawal can persist beyond 72 hours 2

Essential Adjunctive Treatments

Thiamine Supplementation

• Prophylactic dosing: 100-300 mg/day orally or IV throughout withdrawal and for 2-3 months after resolution 1, 2
• Therapeutic dosing for established Wernicke encephalopathy: 100-500 mg/day IV for 12-24 weeks 2
• Thiamine deficiency is present in 30-80% of alcohol-dependent patients 2

Fluid and Electrolyte Management

• Provide aggressive fluid replacement with careful electrolyte repletion, especially magnesium supplementation, as magnesium is commonly depleted in chronic alcohol use 1, 6
• Avoid excessive water-sodium intake in patients with heart disease due to risk of pulmonary edema 3

Management of Specific Complications

Withdrawal Seizures

• Benzodiazepines are the only effective treatment for alcohol withdrawal seizures—do not use anticonvulsants (phenytoin, carbamazepine) for seizure prophylaxis, as they are ineffective and may worsen outcomes 1, 2, 5
• Administer benzodiazepines immediately for any seizure activity 5, 3

Delirium Tremens and Severe Agitation

• Escalate benzodiazepine dosing aggressively for delirium tremens 2
• Haloperidol 0.5-5 mg PO/IM may be added only as adjunctive therapy to adequate benzodiazepine regimens for severe agitation or psychosis—never use as monotherapy, as antipsychotics lower seizure threshold 1, 2
• For benzodiazepine-refractory severe withdrawal in ICU settings, consider phenobarbital or propofol as second-line agents 1, 6

Beta-Blockers (Adjunctive Only)

• IV propranolol can be added for persistent tachycardia despite adequate benzodiazepines, but never use as monotherapy because beta-blockers do not prevent seizures or delirium tremens 1

Monitoring Protocol

• Continuous vital sign monitoring for autonomic instability during acute phase 1
• Evaluate for dangerous complications: dehydration, electrolyte imbalance, infection (pneumonia, spontaneous bacterial peritonitis), GI bleeding, pancreatitis, hepatic encephalopathy 1, 2
• Regular monitoring can be stopped after 24 hours if no specific withdrawal signs appear 1
• Monitor daily for up to 5 days after last drink to verify symptom improvement 1

Post-Acute Management and Relapse Prevention

Mandatory Psychiatric Consultation

• Psychiatric consultation is mandatory after stabilization for evaluation of alcohol use disorder severity, ongoing treatment planning, and long-term abstinence strategies 1, 2

Relapse-Prevention Pharmacotherapy (After Withdrawal Completion)

• Acamprosate (≈2 g/day for patients ≥60 kg): reduces craving, safe in liver disease 1, 2
• Baclofen (up to 80 mg/day): the only medication with proven safety in cirrhotic patients 1, 2
• Naltrexone (25 mg for 1-3 days, then 50 mg daily): decreases heavy drinking but contraindicated in alcoholic liver disease due to hepatotoxicity risk 1, 2
• Disulfiram (500 mg daily for 1-2 weeks, then 125-500 mg daily): induces unpleasant reactions with alcohol but contraindicated in severe alcoholic liver disease 2
• Topiramate may also be considered as an alternative 1

Psychosocial Support

• Encourage engagement with mutual-help groups such as Alcoholics Anonymous 2
• Dispense psychoactive medications in limited quantities or under supervised administration to minimize misuse risk 1, 2

Outpatient Management (Selected Low-Risk Patients Only)

Outpatient treatment is appropriate only for patients with mild to moderate withdrawal who lack serious complications 1:

• Daily physician visits required for 3-5 days after last drink 1
• Use long-acting benzodiazepines (chlordiazepoxide preferred) with symptom-triggered dosing 1
• Thiamine 100-300 mg/day orally mandatory 1
• Adequate social support and ability to return immediately if symptoms worsen 1