What is the recommended assessment and pharmacologic management for acute alcohol withdrawal?

Alcohol Withdrawal: Assessment and Pharmacologic Management

Immediate Assessment Protocol

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

Critical Initial Actions (Within Minutes)

• Administer thiamine 100–500 mg IV immediately before any glucose-containing fluids to prevent precipitating acute Wernicke encephalopathy in all patients with suspected alcohol withdrawal 1, 2
• Obtain finger-stick glucose and correct hypoglycemia only after thiamine administration 1
• Assess vital signs specifically for autonomic instability: tachycardia (>100 bpm), hypertension (systolic >140 mmHg), fever (>38°C), and diaphoresis 1, 2
• Evaluate hand tremor intensity, hyperreflexia, anxiety level, and presence of nausea/vomiting as markers of withdrawal severity 1

Risk Stratification for Hospital Admission

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

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

Use CIWA-Ar for Severity Assessment

• Initiate pharmacologic treatment when CIWA-Ar ≥8; scores ≥15 indicate severe withdrawal requiring aggressive management 1
• The CIWA-Ar assesses 10 domains: tremor, sweating, anxiety, agitation, tactile/auditory/visual disturbances, headache, orientation, and nausea/vomiting 1

First-Line Pharmacologic Management

Long-Acting Benzodiazepines (Preferred for Most Patients)

Long-acting benzodiazepines provide superior protection against seizures and delirium tremens compared to short-acting agents. 1, 3

Diazepam Dosing (FDA-Approved)

• Initial dose: 10 mg orally or IV, then 5–10 mg every 6–8 hours during the first 24 hours 1, 4
• FDA label specifies: 10 mg 3–4 times during first 24 hours, reducing to 5 mg 3–4 times daily as needed 4
• Provides smooth withdrawal coverage due to long half-life and active metabolites 3

Chlordiazepoxide Dosing

• Loading dose: 50–100 mg orally, then 25–100 mg every 4–6 hours based on CIWA-Ar scores (maximum 300 mg in first 24 hours) 1
• Effective alternative long-acting agent with similar seizure protection 1, 3

Short-Acting Benzodiazepines (For Specific Populations)

Switch to lorazepam in patients with hepatic dysfunction, elderly patients, respiratory compromise, obesity, or recent head trauma to avoid drug accumulation and excessive sedation. 1, 2

Lorazepam Dosing

• 2–4 mg orally, IV, or IM every 4–6 hours (total daily dose 6–12 mg) 1, 2
• Preferred in cirrhotic patients due to shorter half-life and minimal hepatic metabolism 1
• Over 70% of cirrhotic patients may not require benzodiazepines at all; use symptom-triggered dosing only when CIWA-Ar ≥8 1, 2

Duration and Tapering

• Limit total benzodiazepine therapy to maximum 10–14 days to prevent iatrogenic dependence 1, 2
• Begin taper after approximately 96 hours (day 4) when acute symptoms are improving 1
• Reduce daily dose by 25% every 2–3 days for long-acting agents, monitoring for rebound anxiety, tremor, or autonomic instability 1
• Never discontinue abruptly; always taper gradually even after short courses 1

Essential Adjunctive Treatments

Thiamine Supplementation Protocol

• Continue thiamine 100–300 mg/day orally or IV throughout withdrawal and for 2–3 months after resolution to support neurologic recovery 1, 2
• High-risk patients (malnourished, severe withdrawal, suspected Wernicke) require 100–500 mg IV daily 2

Fluid and Electrolyte Management

• Provide aggressive fluid replacement with careful magnesium supplementation, as magnesium is commonly depleted in chronic alcohol use 1
• Monitor for dehydration, electrolyte imbalances (especially hypomagnesemia), and metabolic derangements 1

Continuous Monitoring Requirements

• Frequent vital signs to detect autonomic instability 1, 2
• Assess for dangerous complications: infection (pneumonia, spontaneous bacterial peritonitis), gastrointestinal bleeding, pancreatitis, hepatic encephalopathy, and renal failure 1, 2

Management of Specific Complications

Withdrawal Seizures (12–48 Hours After Last Drink)

• Benzodiazepines are the only effective treatment for preventing and treating alcohol withdrawal seizures 1, 5
• Do not use anticonvulsants (phenytoin, carbamazepine) for seizure prophylaxis; they are ineffective and may worsen outcomes 1, 2, 5
• Long-term antiepileptic drugs are unnecessary if patient remains abstinent 5

Delirium Tremens (Peak 48–72 Hours, Up to Day 5)

• Escalate benzodiazepine dosing aggressively for confusion, hallucinations, and severe autonomic instability 1, 6
• Haloperidol 0.5–5 mg may be added only as adjunctive therapy for severe agitation or hallucinations not controlled by benzodiazepines; never use as monotherapy because it lowers seizure threshold 1, 2
• Consider second-line agents (phenobarbital or propofol) for benzodiazepine-refractory cases in ICU settings 1, 7
• Untreated delirium tremens carries up to 50% mortality; with appropriate treatment mortality is <3% 6, 8

Medications to Avoid

• Naltrexone is contraindicated in alcoholic liver disease due to hepatotoxicity risk 1, 2, 3
• Disulfiram is contraindicated in severe alcoholic liver disease due to hepatotoxicity 2, 3
• Antipsychotics as monotherapy increase seizure risk and worsen outcomes 1, 2
• Beta-blockers do not prevent seizures or delirium tremens and should never be used as sole treatment 1

Post-Acute Management and Relapse Prevention

Mandatory Psychiatric Consultation

• Psychiatric evaluation is required after stabilization for assessment 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): safe in liver disease, reduces craving 1, 2
• Baclofen (up to 80 mg/day): the only medication with proven safety in cirrhotic patients for relapse prevention 1, 2
• Naltrexone: contraindicated in alcoholic liver disease 1, 2
• Disulfiram: contraindicated in severe liver disease 2
• Topiramate: emerging evidence for relapse prevention 1

Psychosocial Support

• Encourage engagement with Alcoholics Anonymous or similar mutual-help groups to sustain recovery 1, 2

Critical Pitfalls to Avoid

• Never give glucose-containing IV fluids before thiamine—this can precipitate acute Wernicke encephalopathy 1, 2
• Never rely on anticonvulsants alone for seizure prevention—benzodiazepines remain mandatory 1, 2
• Never use antipsychotics as monotherapy—they increase seizure risk 1, 2
• Never extend benzodiazepine therapy beyond 14 days—this creates iatrogenic dependence 1, 2
• Never discontinue benzodiazepines abruptly—always taper gradually 1
• Do not assume all cirrhotic patients require benzodiazepines—use symptom-triggered dosing 1, 2
• Dispense benzodiazepines in limited quantities or supervise each dose to minimize misuse risk 1, 2

Timeline of Withdrawal Symptoms

• 6–24 hours: tremor, sweating, tachycardia, hypertension, nausea, vomiting, anxiety 1, 6, 9
• 12–24 hours: hallucinations (2–8% of patients) 9
• 12–48 hours: seizures (up to 15% of patients) 6, 9, 5
• 48–72 hours (peak day 3–5): delirium tremens (3–5% of patients) 1, 6, 9
• Up to 1 week: spontaneous resolution of most symptoms 1, 6