What is the recommended management protocol for alcohol withdrawal, including CIWA‑Ar assessment, benzodiazepine dosing, thiamine administration, electrolyte correction, and monitoring?

Management of Alcohol Withdrawal Syndrome

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 and Risk Stratification

Admit to hospital if any of the following are present:

• History of withdrawal seizures or delirium tremens 1, 2
• Severe current symptoms (tremor with vomiting, CIWA-Ar ≥15) 1, 2
• Chronic heavy drinking >80 g/day for ≥10 years 2, 3
• Serious medical comorbidities: liver disease, infection, pancreatitis, GI bleeding, cardiovascular disease 1, 2, 3
• Serious psychiatric illness or active suicide risk 2, 3
• Inadequate social support or failure of prior outpatient treatment 1, 2
• Malnutrition or suspected Wernicke encephalopathy 2, 3

Assess vital signs immediately for autonomic instability: tachycardia, hypertension, fever, diaphoresis—these indicate more severe withdrawal requiring aggressive treatment. 1, 2

Mandatory Thiamine Administration

Give thiamine 100–500 mg IV immediately BEFORE any glucose-containing fluids to prevent precipitating acute Wernicke encephalopathy. 1, 2, 4 This is non-negotiable for every patient with suspected alcohol withdrawal. 2, 3

Continue thiamine 100–300 mg/day (oral or IV) throughout withdrawal and for 2–3 months after resolution. 1, 2, 3

Benzodiazepine Selection and Dosing

For Patients WITHOUT Hepatic Dysfunction (Most Patients)

Use long-acting benzodiazepines—they provide superior protection against seizures and delirium tremens: 1, 2, 4

• Diazepam: 10 mg PO/IV initially, then 5–10 mg every 6–8 hours 1, 2
• Chlordiazepoxide: 50–100 mg PO loading dose, then 25–100 mg every 4–6 hours (maximum 300 mg in first 24 hours) 1, 2

For Patients WITH Hepatic Dysfunction, Elderly, Respiratory Compromise, or Obesity

Switch to short-acting benzodiazepines to avoid drug accumulation and oversedation: 1, 2, 4

• Lorazepam: 2–4 mg PO/IV/IM every 4–6 hours (6–12 mg/day total) 1, 2, 4
• Oxazepam: Alternative short-acting option 2, 3

Critical point for cirrhotic patients: Over 70% may not require benzodiazepines at all—use symptom-triggered dosing only when CIWA-Ar ≥8, not prophylactically. 2, 3

CIWA-Ar Assessment Protocol

Use the Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA-Ar) to quantify withdrawal severity: 2

• CIWA-Ar ≥8: Initiate benzodiazepine therapy 2
• CIWA-Ar ≥15: Severe withdrawal—requires aggressive treatment, never use carbamazepine monotherapy 2
• Reassess CIWA-Ar before each dose to guide symptom-triggered dosing 2, 5

Symptom-triggered dosing is superior to fixed-schedule dosing—it reduces total benzodiazepine exposure, duration of treatment, ICU length of stay, and need for mechanical ventilation. 2, 5

Benzodiazepine Duration and Tapering

Limit total benzodiazepine therapy to a maximum of 10–14 days to prevent iatrogenic dependence. 2, 3

Begin tapering after approximately 96 hours (day 4) when acute symptoms are improving: 2

• Long-acting agents: Reduce daily dose by 25% every 2–3 days 2
• Short-acting agents: Reduce daily dose by 10–25% every 2–4 days 2
• Never discontinue abruptly—always taper gradually 2

Monitor during taper for: rebound anxiety, tremor, autonomic instability (tachycardia, hypertension, sweating), seizures, or altered mental status. 2

Essential Supportive Care

Fluid and electrolyte replacement with aggressive magnesium supplementation—magnesium is commonly depleted in chronic alcohol use. 1, 2, 4

Continuous vital sign monitoring for autonomic instability and assessment for complications: dehydration, electrolyte imbalance, infection (pneumonia, spontaneous bacterial peritonitis), GI bleeding, pancreatitis, hepatic encephalopathy. 1, 2, 3

Management of Specific Complications

Withdrawal Seizures

Benzodiazepines are the only effective treatment for alcohol withdrawal seizures—give diazepam 10 mg IV immediately, then 5–10 mg every 3–4 hours. 2, 4

Do NOT use anticonvulsants (phenytoin, carbamazepine) for seizure prevention after an alcohol withdrawal seizure—they are ineffective and may worsen outcomes. 2, 3, 4

Delirium Tremens (48–72 Hours After Cessation)

Escalate benzodiazepine dosing aggressively. 2, 3

Haloperidol 0.5–5 mg PO/IM may be added ONLY as adjunctive therapy for severe agitation or hallucinations not controlled by benzodiazepines—never as monotherapy because it lowers seizure threshold. 1, 2, 3

Refractory Severe Withdrawal

For benzodiazepine-refractory cases in ICU: phenobarbital or propofol may be used as second-line sedatives. 2

Dexmedetomidine may be added as adjunctive therapy to reduce benzodiazepine requirements, but it does NOT prevent seizures or delirium tremens and must never be used as monotherapy. 2

Medications to AVOID

Never use as monotherapy or for seizure prevention:

• Anticonvulsants (phenytoin, carbamazepine)—ineffective for withdrawal seizures 2, 3, 4
• Antipsychotics alone—lower seizure threshold and worsen outcomes 2, 3
• Beta-blockers alone—do not prevent seizures or delirium tremens; may be used only as adjuncts for persistent tachycardia despite adequate benzodiazepines 2, 6

Carbamazepine 200 mg PO every 6–8 hours may be used as a benzodiazepine-sparing agent ONLY in patients with severe hepatic impairment or benzodiazepine abuse history, but NEVER as monotherapy for CIWA-Ar ≥15 or in patients at risk for seizures. 1, 2

Post-Acute Management and Relapse Prevention

Mandatory psychiatric consultation after stabilization for evaluation of alcohol use disorder severity and long-term abstinence planning. 1, 2, 3, 4

Initiate relapse-prevention pharmacotherapy after withdrawal completion:

• Acamprosate (≈2 g/day for patients ≥60 kg)—safe in liver disease, reduces craving 1, 2, 3
• Baclofen (up to 80 mg/day)—the ONLY medication with proven safety in cirrhotic patients 1, 2, 3
• Naltrexone—CONTRAINDICATED in alcoholic liver disease due to hepatotoxicity risk 1, 2, 3
• Disulfiram—CONTRAINDICATED in severe alcoholic liver disease 2, 3
• Topiramate—emerging evidence for relapse prevention 2, 4

Encourage engagement with Alcoholics Anonymous or similar mutual-help groups. 2, 3

Critical Pitfalls to Avoid

• Never give glucose-containing IV fluids before thiamine—this precipitates acute Wernicke encephalopathy 1, 2, 3, 4
• Never extend benzodiazepines beyond 14 days—creates iatrogenic dependence 2, 3
• Never use anticonvulsants for seizure prevention—benzodiazepines are mandatory 2, 3, 4
• Never use antipsychotics as monotherapy—they increase seizure risk 2, 3
• Never assume all cirrhotic patients need benzodiazepines—use symptom-triggered dosing only 2, 3
• Never prescribe naltrexone in alcoholic liver disease—hepatotoxicity risk 1, 2, 3
• Dispense benzodiazepines in small quantities or supervise each dose to minimize misuse risk 2, 3

Timeline of Withdrawal Symptoms

• 6–24 hours: Tremor, sweating, tachycardia, hypertension, nausea, vomiting, anxiety, agitation 1, 2, 7
• 12–24 hours: Hallucinations (2–8% of patients) 2, 7
• 12–48 hours: Seizures (up to 15% of patients) 2, 4, 7
• 48–72 hours (peak day 3–5): Delirium tremens (3–5% of patients)—confusion, severe autonomic instability, 50% mortality if untreated 1, 2, 7
• Resolution: Typically within one week, but symptoms can persist up to two weeks 2, 7