What is the recommended protocol for assessing and managing alcohol withdrawal in an adult, including CIWA‑Ar (Clinical Institute Withdrawal Assessment for Alcohol, revised) scoring, thiamine supplementation, benzodiazepine regimen (symptom‑triggered versus fixed‑dose), alternatives for hepatic impairment, monitoring parameters, and discharge criteria?

Management of Alcohol Withdrawal

Benzodiazepines are the mandatory first-line therapy for alcohol withdrawal—they are the only proven treatment that prevents seizures and reduces mortality from delirium tremens—and must be combined with immediate thiamine administration before any glucose-containing fluids. 1

Immediate Assessment & Risk Stratification

Thiamine First, Always:

• Administer thiamine 100–500 mg IV immediately before any glucose to prevent precipitating acute Wernicke encephalopathy in every patient with suspected alcohol withdrawal 1, 2
• Continue thiamine 100–300 mg/day orally for 2–3 months after withdrawal resolution 1, 2

Determine Inpatient vs. Outpatient Management:

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

• Prior withdrawal seizures or delirium tremens
• Chronic heavy drinking >80 g/day for ≥10 years
• Significant current withdrawal symptoms (tremor with vomiting, tachycardia, hypertension, sweating)
• CIWA-Ar score ≥15 (severe withdrawal)
• Serious medical comorbidities: liver disease, infection, pancreatitis, GI bleeding, cardiovascular disease
• Serious psychiatric illness or active suicide risk
• Inadequate social support or failure of prior outpatient treatment
• Malnutrition or suspected Wernicke encephalopathy

CIWA-Ar Scoring Protocol:

• Use the Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar) as the gold standard assessment tool 1
• Score ≥8 indicates need for pharmacological treatment 3, 4
• Score ≥15 indicates severe withdrawal requiring aggressive management and hospital admission 1
• Reassess every 1–2 hours during active withdrawal for symptom-triggered dosing 4

Benzodiazepine Regimen Selection

For Most Patients (Normal Liver Function):

• Long-acting benzodiazepines provide superior protection against seizures and delirium tremens 1, 5
• Diazepam: 10 mg PO/IV initially, then 5–10 mg every 3–4 hours as needed based on CIWA-Ar 1
• Chlordiazepoxide: 50–100 mg PO loading dose, then 25–100 mg every 4–6 hours as needed (maximum 300 mg in first 24 hours) 1

For Hepatic Impairment, Elderly, or Respiratory Compromise:

• Switch to lorazepam 2–4 mg PO/IV every 4–6 hours (no active metabolites, shorter half-life) 1, 5, 3
• Oxazepam is an alternative short-acting option in liver disease 1, 3
• Over 70% of cirrhotic patients may not require benzodiazepines at all—use symptom-triggered dosing only when CIWA-Ar ≥8 1, 2

Symptom-Triggered vs. Fixed-Dose:

• Symptom-triggered dosing (guided by repeated CIWA-Ar assessments every 1–2 hours) reduces total benzodiazepine exposure and treatment duration 4, 6
• Fixed-schedule dosing may be used in patients unable to communicate symptoms reliably 1

Critical Benzodiazepine Safety Limits

• Limit total benzodiazepine therapy to maximum 10–14 days to prevent iatrogenic dependence 1, 2
• Begin tapering after day 4 (96 hours) when acute symptoms are improving: reduce daily dose by 25% every 2–3 days for long-acting agents 1
• Never discontinue abruptly—always taper gradually 1
• Dispense in small quantities or supervise each dose to minimize misuse risk 1, 2

Essential Supportive Care

Fluid & Electrolyte Management:

• Aggressive fluid replacement with careful attention to magnesium supplementation—magnesium is commonly depleted in chronic alcohol use 1
• Monitor and correct other electrolyte abnormalities (potassium, phosphate) 1

Continuous Monitoring:

• Vital signs every 2–4 hours for autonomic instability: tachycardia, hypertension, fever, sweating 1, 2
• Assess for dangerous complications: dehydration, infection (pneumonia, spontaneous bacterial peritonitis), GI bleeding, pancreatitis, hepatic encephalopathy 1, 2

Management of Specific Complications

Seizures:

• Benzodiazepines are the only effective treatment for alcohol withdrawal seizures 1, 5
• Do NOT use phenytoin, carbamazepine, or other anticonvulsants—they are ineffective for withdrawal seizures and may worsen outcomes 1, 2, 5
• Withdrawal seizures result from rebound CNS hyperexcitability (unopposed glutamate excitation after loss of GABA inhibition), not true epileptic activity 5

Delirium Tremens (48–72 hours post-cessation):

• Escalate benzodiazepine dosing aggressively 1
• Haloperidol 0.5–5 mg PO/IM may be added as adjunctive therapy for severe agitation or hallucinations, but never as monotherapy (lowers seizure threshold) 1, 2
• Consider phenobarbital or propofol as second-line sedatives for benzodiazepine-refractory cases 1

Beta-Blockers:

• May be added for persistent tachycardia despite adequate benzodiazepines, but never as monotherapy—they do not prevent seizures or delirium tremens 1

Alternative Agents in Special Populations

Carbamazepine:

• May be used as benzodiazepine-sparing agent in patients with severe hepatic impairment, benzodiazepine dependence history, or high oversedation risk 1
• Absolute contraindication: CIWA-Ar ≥15 (severe withdrawal) 1
• Never use as monotherapy for moderate-to-severe withdrawal—benzodiazepines remain mandatory 1
• Limit duration to 10–14 days 1

Baclofen:

• The only medication with proven safety in cirrhotic patients for both withdrawal and relapse prevention 1, 2
• Dose up to 80 mg/day 1, 2
• Use as adjunct or alternative when benzodiazepines pose unacceptable accumulation risk in severe liver disease 1
• Never use as monotherapy for CIWA-Ar ≥15 or in patients at risk for seizures/delirium tremens 1

Discharge Criteria & Post-Acute Management

Safe for Discharge When:

• CIWA-Ar consistently <8 for 24 hours 1
• Vital signs stable without autonomic instability 1
• No evidence of delirium, hallucinations, or severe agitation 1
• Adequate oral intake and hydration 1
• Safe discharge plan with follow-up arranged 1

Mandatory Psychiatric Consultation:

• Required for every patient after stabilization to assess alcohol use disorder severity and develop long-term abstinence plan 1, 2

Relapse Prevention Pharmacotherapy (Post-Withdrawal)

Medication	Dosing	Key Points	Contraindications
Acamprosate	≈2 g/day (≥60 kg)	Safe in liver disease; reduces craving [1,2]	None in liver disease
Naltrexone	25 mg × 1–3 days, then 50 mg daily	Decreases heavy drinking [2]	Contraindicated in alcoholic liver disease (hepatotoxicity) [1,2]
Baclofen	Up to 80 mg/day	Only medication proven safe in cirrhosis [1,2]	None in liver disease
Disulfiram	500 mg daily × 1–2 weeks, then 125–500 mg daily	Aversive therapy [2]	Contraindicated in severe liver disease [1,2]
Topiramate	Titrate gradually	Emerging evidence for relapse prevention [1]	Use caution

Psychosocial Support:

• Encourage participation in Alcoholics Anonymous or similar mutual-help groups 1, 2
• Arrange motivational interviewing and structured psychological therapies 2

Critical Pitfalls to Avoid

• Never give glucose-containing IV fluids before thiamine—precipitates Wernicke encephalopathy 1, 2
• Never use anticonvulsants alone for seizure prevention—benzodiazepines are mandatory 1, 2, 5
• Never use antipsychotics as monotherapy—they lower seizure threshold and worsen outcomes 1, 2
• Never extend benzodiazepines beyond 14 days or stop abruptly—always taper 1, 2
• Do not assume all cirrhotic patients need benzodiazepines—use symptom-triggered dosing only when CIWA-Ar ≥8 1, 2
• Do not prescribe naltrexone in alcoholic liver disease—hepatotoxicity risk 1, 2
• Do not discontinue benzodiazepines prematurely based on day of admission alone—treat until symptom resolution 2