- Autonomic hyperactivity.
- Increased hand tremor.
- Insomnia.
- Nausea or vomiting.
- Transient visual, tactile or auditory hallucinations.
- Anxiety.
- GTC seizures.
Severe alcohol withdrawal syndrome: intense autonomic and psychological symptoms AND withdrawal seizures, delirium tremens, or both.
Initial Assessment
- Airway, breathing, circulation, disability.
- Recognition of concurrent trauma.
- Administer thiamine for empiric prevention of Wernicke’s encephalopathy (WE) or Korsakoff’s psychosis.
- If WE clinically suspected, administer thiamine 500 mg IV q8h for 72h.
- If low suspicion for WE, administer thiamine 100 mg daily. Thiamine should be replete IV x 3 days in the acute setting due to minimal PO absorption.
- If volume depleted, administer IV fluid bolus.
- Diazepam 5-10 mg IV, repeated in 5-10 minutes if needed.
- Lorazepam 2-4 mg IV, repeated in 5-10 minutes if needed.
- Midazolam 2-4 mg IM, if no IV access.
- Secure airway.
- Admit to ICU.
- Progression from benzodiazepines to phenytoin/fosphenytoin, to phenobarbital, to valproic acid, to propofol and pentobarbital.
- For all alcohol withdrawal hospitalizations, evaluate for co-occurring medical conditions (alcoholic hepatitis, pancreatitis, cirrhosis, gastrointestinal bleed, infection, trauma, hypoglycemia, co-ingestions, arrhythmias, dilated cardiomyopathy, altered electrolytes).
- If febrile, rule out infection.
- Ethanol level is generally not helpful; negative level does not rule out withdrawal, and some patients show signs of withdrawal with toxic ethanol levels. Consider sending if history or presentation is unclear.
- Check ECG if considering giving haloperidol as part of treatment.
Management
PAWSS (Prediction of Alcohol Withdrawal Severity Scale)
- Consists of 3 parts: 1) threshold criteria 2) patient questions 3) clinical evaluation.
- Once risk for withdrawal assessed, determine need for initiation of alcohol withdrawal treatment.
- Use a CIWA protocol (see below) to administer benzodiazepines with or without adjunctive haloperidol.
- Can also start adjunctive gabapentin (300-600 TID) to decrease benzodiazepine requirements. Limited data for gabapentin in alcohol use disorder treatment.
- Seizure precautions if deemed at risk.
- Assessment for alcohol use disorder and motivational interviewing.
CIWA
- CIWA was originally designed as a tool for alcohol withdrawal research and is validated only in mild to moderate alcohol withdrawal.
- Studies on CIWA have frequently excluded patients with seizures.
- CIWA does not include vital sign assessment, which is an important part of recognizing severe alcohol withdrawal syndrome.
- Consider lorazepam for use in the elderly, those with liver disease, or if NPO.
- Do not mix BZD (e.g., if using lorazepam scheduled, use lorazepam for breakthrough).
- Oral administration is preferred, as is symptom-triggered rather than a standing administration.
- Symptom triggered protocols are preferred over fixed dose protocols given decreased mean amount of BZD used, decreased total duration of treatment and decreased length of hospital stay.
Assess CIWA score: < 8 = not yet in withdrawal, >8 = withdrawing, > 25 = needs monitoring.
- CIWA scores can be calculated online or with set protocol forms.
Withdrawal prophylaxis
- Use only if initial CIWA < 8 (not in withdrawal). Assess CIWA and sedation scale every 6 hours and 1 hour after admin of BZD. Hold BZD for sedation, assess vitals.
- Assess risk class based on history, degree of alcohol abuse, etc. Risk level:
- Mild: diazepam 5 mg PO/IV, or chlordiazepoxide 25 mg PO, or lorazepam 1 mg PO/IV/SL/IM every 6 hours and q1h prn for CIWA > 8.
- Moderate: diazepam 10 mg PO/IV, or chlordiazepoxide 50 mg PO, or lorazepam 2 mg as above.
- Severe: diazepam 20 mg PO/IV, chlordiazepoxide 75-100 mg PO, or lorazepam 3-4 mg as above.
Initial treatment of acute withdrawal
- CIWA 8-25. Goal is to achieve CIWA < 8.
- Assess CIWA and sedation scale every 4 hours and 1 hour after admin of BZD. Hold BZD for sedation, assess vitals.
- Mild (CIWA 8-15): diazepam 10 mg PO/IV, or chlordiazepoxide 50 mg PO, or lorazepam 1-2 mg PO/IV/SL/IM q 1 hour x 2.
- Moderate (CIWA 16-25): diazepam 20 mg PO/IV, or chlordiazepoxide 100 mg PO, or lorazepam 3-4 mg PO/IV/SL/IV q 1 hour x 2.
Ongoing treatment of acute withdrawal
- CIWA < 8 after treatment of acute withdrawal. Goal is to keep CIWA < 8.
- Diazepam 10-20 mg PO/IV, or chlordiazepoxide 50-100 mg PO (NTE 600 mg/24 hours), or lorazepam 3-4 mg PO/IV/SL/IM every 6 hours ATC and q1h prn CIWA > 8.
- Taper benzodiazepines by 25% per day once stable for 24 hours.
Treatment of severe withdrawal
- CIWA > 25 or uncontrolled severe symptoms.
- Transfer/admit to monitored setting with continuous oxygen and telemetry.
- CIWA and sedation score every 2 hours and 15-30 min after IV BZD administration.
- Diazepam 10-20 mg IV or lorazepam 2-4 mg IV every 15-30 minutes for six hours.
- Titrate to CIWA < 8 or moderate sedation.
- If total requirements are > 200 mg diazepam in 3 hours (or > 40 mg lorazepam), consider starting gtt or benzo refractory adjuncts. Be aware that the carrier agents in some IV lorazepam preparations can themselves be toxic (propylene glycol).
- Phenobarbital for withdrawal seizures, initial dose of 260 mg IV, then 130 mg every 30 minutes until signs of mild intoxication.
- Dexmedetomidine (DEX) may be considered as an adjunct to benzodiazepines in treating symptoms of autonomic hyperactivity.
- Does not have anti-convulsant prosperities.
- Insufficient data to determine if DEX will reduce need for intubation or affect length of stay.
- Studies report higher incidence of cardiovascular effects, mechanical ventilation, pneumonia.
- Use only in patients who have failed or cannot tolerate other agents.
Example protocols:
- Use of barbiturate only (phenobarbital) or barbiturate/benzodiazepine combination protocols have been shown to be effective.
- Consider use of adjuvant pharmacologic therapy:
- Gabapentin 1800 mg/day used during first 2 days of hospital admission significantly lowered total dose of benzodiazepines.
- Gabapentin appears to be more beneficial for mild rather than severe alcohol withdrawal.
- High dose Gabapentin (1800 mg/day) is also associated with decrease in percentage of heavy drinking days.
CIWA protocol adapted from San Francisco General Hospital CIWA protocol form.
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- Gabapentin 1800 mg/day used during first 2 days of hospital admission significantly lowered total dose of benzodiazepines.