How should acute alcohol withdrawal be assessed and treated, including CIWA‑Ar (Clinical Institute Withdrawal Assessment for Alcohol, revised) scoring, benzodiazepine regimens, thiamine supplementation, electrolyte correction, monitoring, and alternative therapies if benzodiazepines are contraindicated?

Management of Acute Alcohol Withdrawal

Benzodiazepines are the mandatory first-line treatment for alcohol withdrawal—they are the only proven therapy that prevents seizures and reduces mortality from delirium tremens. 1, 2

Immediate Assessment & Risk Stratification

Before any treatment, assess for factors requiring inpatient admission:

• History of withdrawal seizures or delirium tremens 1, 2
• Significant current withdrawal signs: tremor, tachycardia (>100 bpm), hypertension (>160/100), fever, diaphoresis 1, 3
• Chronic heavy use (>80 g/day for ≥10 years) 1, 2
• Co-existing serious medical illness: liver disease, infection, gastrointestinal bleeding, pancreatitis, cardiovascular disease 1, 2
• Co-existing psychiatric illness or suicide risk 1, 2
• Inadequate social support or prior outpatient treatment failure 1, 2

Screen for dangerous complications immediately:

• Dehydration and electrolyte imbalance (especially magnesium and potassium) 1, 2
• Hypoglycemia (check finger-stick glucose) 4
• Infection (pneumonia, spontaneous bacterial peritonitis in cirrhotics) 1, 2
• Hepatic encephalopathy in patients with known liver disease 1, 2
• Wernicke encephalopathy (confusion, ataxia, ophthalmoplegia) 1, 2

CIWA-Ar Scoring for Symptom-Triggered Dosing

Use the Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA-Ar) to quantify withdrawal severity and guide benzodiazepine dosing: 1

• CIWA-Ar ≥8: Initiate benzodiazepine therapy 1
• CIWA-Ar ≥15: Absolute contraindication to carbamazepine monotherapy; requires benzodiazepines 1
• Reassess CIWA-Ar every 1–4 hours during active withdrawal to guide additional dosing 1, 5

The CIWA-Ar assesses 10 domains: tremor, sweating, anxiety, agitation, tactile/auditory/visual disturbances, headache, orientation, and nausea/vomiting. 1

Mandatory Thiamine Administration

Administer thiamine 100–500 mg IV immediately BEFORE any glucose-containing fluids to prevent precipitating acute Wernicke encephalopathy. 1, 2, 4

• This applies to every patient with alcohol withdrawal, regardless of severity 1, 2
• Continue thiamine 100–300 mg/day orally throughout withdrawal and for 2–3 months after resolution 1, 2
• If Wernicke encephalopathy is suspected (confusion, ataxia, ophthalmoplegia), increase to 500 mg IV daily for 12–24 weeks 2

Common pitfall: Never give dextrose-containing IV fluids before thiamine—this can precipitate acute Wernicke encephalopathy. 1, 2

Benzodiazepine Regimens

Long-Acting Benzodiazepines (Preferred for Most Patients)

Long-acting agents (diazepam, chlordiazepoxide) provide superior protection against seizures and delirium tremens compared to short-acting agents. 1, 2, 6

Chlordiazepoxide dosing:

• Initial: 50–100 mg orally, then 25–100 mg every 4–6 hours as needed based on CIWA-Ar 1, 6
• Maximum: 300 mg in the first 24 hours 6
• Mild withdrawal: 25–50 mg every 4–6 hours 6

Diazepam dosing:

• Oral: 10 mg every 3–4 hours during the first 24 hours 1
• IV (severe withdrawal with altered consciousness): 10 mg initially, then 5–10 mg every 3–4 hours 1

Short-Acting Benzodiazepines (For Specific Populations)

Switch to lorazepam 6–12 mg/day (divided every 4–6 hours) or oxazepam in patients with: 1, 2, 6

• Hepatic dysfunction or cirrhosis 1, 2
• Advanced age (>65 years) 1, 2
• Obesity 1, 6
• Respiratory compromise 1, 2
• Recent head trauma 1, 2

Important nuance: Despite widespread belief, the superiority of short-acting benzodiazepines in liver disease is not validated by controlled trials—all benzodiazepines are affected by hepatic insufficiency. 2 However, lorazepam's shorter half-life reduces the risk of "dose-stacking" and excessive sedation. 1

Symptom-Triggered vs. Fixed-Schedule Dosing

Symptom-triggered dosing (based on repeated CIWA-Ar assessments) minimizes total benzodiazepine exposure and is preferred when close monitoring is available. 1, 7, 5

• Reassess CIWA-Ar every 1–4 hours 5
• Administer benzodiazepines when CIWA-Ar ≥8 1

Fixed-schedule dosing may be used when frequent reassessment is not feasible, but carries higher risk of over- or under-treatment. 1

Duration and Tapering

Limit benzodiazepine therapy to a maximum of 10–14 days to prevent iatrogenic dependence. 1, 2

• Begin tapering after approximately 96 hours (day 4) when acute symptoms are improving 1
• Long-acting agents: Reduce daily dose by 25% every 2–3 days 1
• Short-acting agents: Reduce daily dose by 10–25% every 2–4 days 1
• Monitor for rebound anxiety, tremor, tachycardia, or autonomic instability during taper 1

Common pitfall: Never discontinue benzodiazepines abruptly—even after short courses, rebound withdrawal can occur. 1

Electrolyte Correction

Aggressively replace fluids and electrolytes, with particular attention to magnesium: 1, 2

• Magnesium is commonly depleted in chronic alcohol use 1
• Correct hypokalemia, hypophosphatemia, and hypomagnesemia 1, 3
• Monitor for dehydration and provide IV fluids as needed 1, 2

Monitoring Protocol

Continuous vital-sign monitoring is crucial for detecting autonomic instability: 1, 2

• Tachycardia, hypertension, hyperthermia, diaphoresis 1, 3
• Assess vital signs before each benzodiazepine dose 1

Timeline of withdrawal complications:

• 6–24 hours: Tremor, anxiety, nausea, vomiting, autonomic hyperactivity 1, 4
• 12–24 hours: Hallucinations (2–8% of patients) 4
• 12–48 hours: Seizures (up to 15% of patients) 4
• 48–72 hours (peak day 3–5): Delirium tremens (3–5% of patients; mortality up to 50% if untreated) 1, 4

Outpatient monitoring: Daily physician visits for 3–5 days after the last drink to verify symptom improvement and assess need for additional treatment. 1, 5

Inpatient monitoring: Regular monitoring can be stopped after 24 hours if no specific withdrawal signs appear, but continue daily assessment for up to 5 days. 1, 2

Management of Specific Complications

Seizures

Benzodiazepines are the only effective treatment for alcohol-withdrawal seizures. 1, 2

• Do not use anticonvulsants (phenytoin, carbamazepine) for seizure prophylaxis—they are ineffective and may worsen outcomes. 1, 2, 6
• Alcohol-withdrawal seizures are rebound phenomena with lowered seizure threshold, not genuine seizures requiring chronic anticonvulsant therapy 1

Delirium Tremens

Delirium tremens presents with confusion, hallucinations, severe autonomic instability, and typically emerges 48–72 hours after cessation. 1, 4

• Escalate benzodiazepine dosing aggressively 1, 2
• Haloperidol 0.5–5 mg PO/IM may be added as adjunctive therapy for severe agitation or psychosis, but never as monotherapy. 2, 8
• Antipsychotics alone lower the seizure threshold and worsen outcomes 2

Refractory Withdrawal

For severe withdrawal inadequately controlled with benzodiazepines, second-line agents include: 1

• Phenobarbital (barbiturate) 1
• Propofol 1
• Dexmedetomidine (adjunctive only; does not prevent seizures or delirium tremens) 1

These patients require ICU admission and may progress to intubation and mechanical ventilation. 4

Alternative Therapies if Benzodiazepines Are Contraindicated

Carbamazepine 200 mg every 6–8 hours can be used as a benzodiazepine-sparing agent in patients with: 1, 6

• Severe hepatic impairment 1
• History of benzodiazepine dependence/abuse 1
• High risk of oversedation 1

Absolute contraindications to carbamazepine monotherapy:

• CIWA-Ar ≥15 (severe withdrawal) 1
• Risk of seizures or delirium tremens 1

Carbamazepine must be used only as adjunctive therapy in moderate-to-severe withdrawal, not as monotherapy. 1

Other adjunctive agents (not replacements for benzodiazepines):

• Beta-blockers (e.g., propranolol IV): May be added for persistent tachycardia despite adequate benzodiazepines, but do not prevent seizures or delirium tremens 1, 3
• Baclofen (up to 80 mg/day): Shows promise for withdrawal management and is the only medication with proven safety in cirrhotic patients 1, 2, 6
• Topiramate: Preliminary evidence for withdrawal management and relapse prevention 1, 6

Special Considerations for Cirrhotic Patients

Over 70% of cirrhotic patients may not require benzodiazepines at all—use symptom-triggered dosing based on clinical assessment, not prophylactic administration. 1, 2

• When benzodiazepines are needed, short-acting agents (lorazepam, oxazepam) are preferred 1, 2
• Monitor closely for hepatic encephalopathy, which can be triggered by alcohol cessation, dehydration, or electrolyte imbalances 1, 2

Post-Acute Management & 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; safe in liver disease 1, 2
• Naltrexone (25 mg for 1–3 days, then 50 mg daily for 3–12 months): Decreases heavy drinking; contraindicated in alcoholic liver disease due to hepatotoxicity risk 1, 2
• 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): Aversive deterrent; contraindicated in severe alcoholic liver disease 2
• Topiramate: Reduces craving and heavy drinking 1

Psychosocial support:

• Encourage engagement with mutual-help groups such as Alcoholics Anonymous 1, 2, 7
• Offer ongoing psychosocial treatment in addition to pharmacotherapy 7, 5

Common pitfall: Do not prescribe addictive substances (including benzodiazepines) beyond the acute withdrawal period—this creates iatrogenic dependence. 1, 7