What is the recommended management of alcohol withdrawal, including assessment with the Clinical Institute Withdrawal Assessment for Alcohol (CIWA‑Ar) and appropriate benzodiazepine regimens?

Management of Alcohol Withdrawal

Benzodiazepines are the mandatory first-line therapy for alcohol withdrawal, being 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 and Thiamine Administration

• Administer thiamine 100–500 mg IV immediately before any glucose-containing fluids to prevent precipitating acute Wernicke encephalopathy in every patient with suspected alcohol withdrawal 1, 2
• Continue thiamine 100–300 mg/day orally throughout withdrawal and for 2–3 months after symptom resolution 1, 2
• Assess vital signs for autonomic instability: tachycardia, hypertension, fever, and diaphoresis indicate severe withdrawal requiring aggressive treatment 1, 2
• Screen for dangerous complications including dehydration, electrolyte imbalance (especially magnesium), infection, gastrointestinal bleeding, pancreatitis, hepatic encephalopathy, and renal failure 1, 2

CIWA-Ar Assessment Protocol

• Use the Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA-Ar) to quantify withdrawal severity 1
• The CIWA-Ar consists of 10 items assessing tremor, sweating, anxiety, agitation, tactile/auditory/visual disturbances, headache, orientation, and nausea/vomiting 1
• Initiate benzodiazepine therapy when CIWA-Ar ≥ 8 1, 2
• CIWA-Ar ≥ 15 indicates severe withdrawal requiring aggressive treatment and hospital admission 1, 2
• Reassess CIWA-Ar every 1–2 hours during active withdrawal to guide symptom-triggered dosing 1

Benzodiazepine Selection and Dosing

For Patients WITHOUT Hepatic Dysfunction (First-Line)

• Long-acting benzodiazepines provide superior protection against seizures and delirium tremens 1, 2
• Diazepam: 10 mg PO/IV initially, then 5–10 mg every 3–4 hours as needed based on CIWA-Ar scores 1, 3
• Chlordiazepoxide: 50–100 mg PO loading dose, then 25–100 mg every 4–6 hours (maximum 300 mg in first 24 hours) 1, 2
• After initial symptom control (typically 3–5 days), begin tapering by reducing daily dose by approximately 25% every 2–3 days 1

For Patients WITH Hepatic Dysfunction, Elderly, or Respiratory Compromise

• Switch to short-acting benzodiazepines to avoid drug accumulation and excessive sedation 1, 2, 4
• Lorazepam: 2–4 mg PO/IV/IM every 4–6 hours (total 6–12 mg/day) 1, 2, 4
• Oxazepam: 15–30 mg PO every 6–8 hours 4
• Over 70% of cirrhotic patients may not require benzodiazepines at all; use symptom-triggered dosing only when CIWA-Ar ≥ 8 1, 2

Critical Benzodiazepine Principles

• Limit total benzodiazepine therapy to a maximum of 10–14 days to prevent iatrogenic dependence 1, 2
• Never discontinue benzodiazepines abruptly; always taper gradually 1
• Dispense in small quantities or supervise each dose to minimize misuse risk 1, 2

Hospital Admission Criteria

Admit patients with any of the following: 1, 2

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

Management of Specific Complications

Withdrawal Seizures (12–48 Hours After Last Drink)

• Benzodiazepines are the only proven therapy to prevent alcohol withdrawal seizures 1, 2
• Do NOT use anticonvulsants (phenytoin, carbamazepine) for seizure prophylaxis; they are ineffective and may worsen outcomes 1, 2
• Escalate benzodiazepine dosing aggressively if seizures occur 1

Delirium Tremens (48–72 Hours After Last Drink, Peak Days 3–5)

• Presents with confusion, hallucinations, severe autonomic instability; mortality ≈50% if untreated 1, 5
• Escalate benzodiazepine dosing aggressively as primary treatment 1, 2
• Haloperidol 0.5–5 mg PO/IM may be added ONLY as adjunctive therapy for severe agitation or hallucinations not controlled by benzodiazepines 1, 2
• Never use antipsychotics as monotherapy; they lower seizure threshold and worsen outcomes 1, 2

Benzodiazepine-Refractory Severe Withdrawal (ICU Setting)

• Phenobarbital or propofol can be used as second-line sedative agents 1
• Dexmedetomidine may be added as adjunctive therapy to reduce benzodiazepine requirements, but never as monotherapy because it does not prevent seizures or delirium tremens 1

Essential Supportive Care

• Aggressive fluid and electrolyte replacement with magnesium supplementation is essential because magnesium is commonly depleted in chronic alcohol use 1, 2
• Continuous vital-sign monitoring to detect autonomic instability and complications 1, 2
• Screen for concurrent infection (pneumonia, spontaneous bacterial peritonitis), gastrointestinal bleeding, pancreatitis, and hepatic encephalopathy 1, 2

Timeline of Withdrawal Symptoms

• 6–24 hours: Tremor, sweating, tachycardia, hypertension, nausea, vomiting, anxiety, agitation 1, 5
• 12–24 hours: Hallucinations (2–8% of patients) 1, 5
• 12–48 hours: Seizures (up to 15% of patients) 1, 5
• 48–72 hours (peak days 3–5): Delirium tremens (3–5% of patients) 1, 5
• Up to 1 week: Symptoms generally resolve spontaneously 1, 5

Post-Acute Management and Relapse Prevention

• Mandatory psychiatric consultation after stabilization to evaluate alcohol-use disorder severity and plan long-term abstinence 1, 2
• Continue thiamine 100–300 mg/day for 2–3 months after withdrawal resolution 1, 2
• Do NOT continue benzodiazepines beyond 10–14 days; transition to relapse-prevention pharmacotherapy 1, 2

Relapse-Prevention Medications (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 1, 2

• Naltrexone (50 mg/day): CONTRAINDICATED in alcoholic liver disease due to hepatotoxicity risk 1, 2

• Disulfiram (125–500 mg/day): CONTRAINDICATED in severe alcoholic liver disease due to hepatotoxicity 1, 2

• Topiramate: Emerging evidence for relapse prevention 1

• Encourage engagement with mutual-help groups such as Alcoholics Anonymous 1, 2

Critical Pitfalls to Avoid

• Never administer glucose-containing IV fluids before thiamine; this can precipitate acute Wernicke encephalopathy 1, 2
• Never use anticonvulsants for withdrawal seizure prophylaxis; benzodiazepines are mandatory 1, 2
• Never use antipsychotics as monotherapy; they increase seizure risk and worsen outcomes 1, 2
• Never extend benzodiazepine therapy beyond 14 days or discontinue abruptly 1, 2
• Never prescribe naltrexone to patients with alcoholic liver disease 1, 2
• Do not assume all cirrhotic patients require benzodiazepines; use symptom-triggered dosing only when CIWA-Ar ≥ 8 1, 2