What is the recommended management of alcohol withdrawal in an adult who has recently reduced or stopped heavy drinking (>5 standard drinks per day for several weeks), including severity assessment, benzodiazepine regimen, thiamine administration, monitoring, and prevention of complications?

Management of Alcohol Withdrawal in Adults

Immediate Assessment and Thiamine Administration

Administer thiamine 100-500 mg intravenously immediately before any glucose-containing fluids to every patient with suspected alcohol withdrawal—this is mandatory to prevent precipitating acute Wernicke encephalopathy. 1, 2, 3

• Assess vital signs for autonomic instability: tachycardia (>100 bpm), hypertension (systolic >140 mmHg), fever (>38°C), and diaphoresis 2, 3
• Evaluate hand tremor intensity, hyperreflexia, agitation level, nausea, and vomiting—these typically begin 6-24 hours after the last drink 2, 4, 5
• Screen for dangerous complications: dehydration, electrolyte imbalances (especially magnesium and potassium), infection (pneumonia, spontaneous bacterial peritonitis), gastrointestinal bleeding, pancreatitis, hepatic encephalopathy, and renal failure 2, 3

Severity Assessment Using CIWA-Ar

• Use the Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA-Ar) to quantify withdrawal severity 2, 6
• CIWA-Ar scores ≥8 indicate need for pharmacological treatment with benzodiazepines 2
• Reassess CIWA-Ar every 1-2 hours during active withdrawal to guide symptom-triggered dosing 6

Inpatient vs. Outpatient Decision

Admit to hospital if any of the following are present: 1, 2, 3, 4

• History of withdrawal seizures or delirium tremens
• Significant current withdrawal symptoms (tremor with vomiting, CIWA-Ar ≥15)
• Chronic heavy drinking >80 g/day for ≥10 years
• Co-existing serious medical illness (liver disease, infection, cardiovascular disease, pancreatitis, gastrointestinal bleeding)
• Co-existing serious psychiatric illness or active suicide risk
• Inadequate social support or unstable housing
• Failure of prior outpatient treatment
• Malnourishment or suspected Wernicke encephalopathy

Outpatient management is appropriate only for: 4, 5

• Mild to moderate withdrawal (CIWA-Ar <15)
• No history of seizures or delirium tremens
• Adequate social support with reliable daily supervision
• No serious medical or psychiatric comorbidities

Benzodiazepine Regimen

First-Line: Long-Acting Benzodiazepines (Most Patients)

Long-acting benzodiazepines (diazepam or chlordiazepoxide) provide superior protection against seizures and delirium tremens and are the preferred choice for most patients. 1, 2, 7, 8

Chlordiazepoxide dosing: 2, 7

• Initial: 50-100 mg orally
• Maintenance: 25-100 mg every 4-6 hours as needed based on CIWA-Ar scores
• Maximum: 300 mg in first 24 hours
• Begin taper after 96 hours (day 4) by reducing daily dose by 25% every 2-3 days
• Complete discontinuation by day 10-14 maximum

Diazepam dosing: 2, 8

• Initial: 10 mg orally or IV
• Maintenance: 5-10 mg every 3-4 hours as needed
• For severe withdrawal with altered consciousness: 10 mg IV initially, then 5-10 mg IV every 3-4 hours

Alternative: Short-Acting Benzodiazepines (Specific Populations)

Switch to lorazepam if the patient has: 2, 3, 7

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

Lorazepam dosing: 2, 3

• 2-4 mg orally/IV/IM every 4-6 hours
• Total daily dose: 6-12 mg/day
• Taper by 10-25% every 2-4 days after symptom control

Critical Benzodiazepine Principles

• Benzodiazepines are the only proven treatment to prevent seizures and reduce mortality from delirium tremens 1, 2, 3, 9, 8
• Limit total duration to 10-14 days maximum to prevent iatrogenic dependence 2, 3
• Never discontinue abruptly—always taper gradually 2
• Dispense in small quantities or supervise each dose to reduce misuse risk 1, 3
• Over 70% of cirrhotic patients may not require benzodiazepines; use symptom-triggered dosing only when CIWA-Ar ≥8 2, 3

Thiamine Administration Protocol

Dosing schedule: 1, 2, 3

• Prophylactic: 100-300 mg/day orally or IV for all patients
• High-risk patients (malnourished, severe withdrawal, suspected Wernicke encephalopathy): 100-500 mg/day IV
• Continue for 2-3 months after withdrawal resolution
• Always give thiamine before any glucose-containing IV fluids—giving glucose first can precipitate acute Wernicke encephalopathy 2, 3

Supportive Care and Monitoring

• Aggressive fluid replacement with attention to electrolyte correction, especially magnesium supplementation 2, 3, 8
• Continuous vital sign monitoring for autonomic instability 2, 3
• Monitor for withdrawal complications: seizures (peak 12-48 hours), hallucinations (12-24 hours), delirium tremens (peak 48-72 hours, up to day 5) 2, 4, 5
• Daily physician visits for 3-5 days after last drink in outpatient settings 2
• Regular monitoring can be stopped after 24 hours if no specific withdrawal signs appear in cirrhotic patients 2

Management of Complications

Withdrawal Seizures

• Do NOT use anticonvulsants (phenytoin, carbamazepine) to prevent further alcohol withdrawal seizures—they are ineffective and may worsen outcomes 1, 2, 3, 7
• Benzodiazepines are the only effective treatment for preventing and treating withdrawal seizures 1, 2, 3
• Ensure adequate benzodiazepine dosing if seizure occurs 8

Delirium Tremens (Severe Withdrawal Delirium)

• Escalate benzodiazepine dosing aggressively 8
• Antipsychotics (haloperidol 0.5-5 mg) may be added ONLY as adjuncts to adequate benzodiazepine doses for severe agitation or hallucinations—never use as monotherapy 1, 2, 3, 9
• Antipsychotics alone lower seizure threshold and worsen outcomes 3
• For benzodiazepine-refractory cases in ICU: consider phenobarbital or propofol as second-line agents 2, 8

Adjunctive Medications (Limited Role)

• Beta-blockers (propranolol IV): may be added for persistent tachycardia despite adequate benzodiazepines, but never as monotherapy—they do not prevent seizures or delirium tremens 2, 9, 5
• Dexmedetomidine: adjunctive therapy only for severe ICU cases refractory to benzodiazepines; does not prevent seizures 2
• Carbamazepine (200 mg every 6-8 hours): alternative only for mild-moderate withdrawal in patients with benzodiazepine contraindications or abuse history; contraindicated if CIWA-Ar ≥15 2, 7, 4, 5

Post-Withdrawal Relapse Prevention

Psychiatric consultation is mandatory after stabilization for evaluation of alcohol use disorder severity and long-term abstinence planning. 2, 3

Pharmacologic relapse prevention options: 1, 2, 3

• Acamprosate (≈2 g/day for patients ≥60 kg): safe in liver disease, reduces craving
• Naltrexone (25 mg for 1-3 days, then 50 mg daily): contraindicated in alcoholic liver disease due to hepatotoxicity risk
• Baclofen (up to 80 mg/day): the only medication with proven safety in cirrhotic patients
• Disulfiram (500 mg daily for 1-2 weeks, then 125-500 mg daily): contraindicated in severe alcoholic liver disease
• Topiramate: emerging evidence for both withdrawal and relapse prevention 7

Psychosocial interventions: 1, 3

• Encourage engagement with Alcoholics Anonymous or other mutual help groups
• Offer motivational interviewing and structured psychological interventions
• Involve family members when appropriate

Critical Pitfalls to Avoid

• Never administer glucose-containing IV fluids before thiamine—this precipitates Wernicke encephalopathy 2, 3
• Never use anticonvulsants alone for withdrawal seizure prevention—benzodiazepines are mandatory 1, 2, 3
• Never use antipsychotics as monotherapy—they worsen outcomes and lower seizure threshold 1, 2, 3
• Never extend benzodiazepines beyond 14 days—this creates iatrogenic dependence 2, 3
• Never discontinue benzodiazepines abruptly—always taper gradually 2
• Do not assume all cirrhotic patients need benzodiazepines—use symptom-triggered dosing only 2, 3
• Do not prescribe naltrexone in patients with alcoholic liver disease—hepatotoxicity risk 2, 3