Alcohol Withdrawal Management

Pathophysiology

Clinical Spectrum & Timeline

Assessment: CIWA-Ar Scale

Investigations

• Labs: BMP (electrolytes, glucose, creatinine), LFTs, CBC, Mg²⁺, phosphate, INR, blood alcohol level, urine toxicology, urine hCG (women)
• ECG (if available)
• Assess for: hypoglycaemia, hypomagnesaemia, hypokalemia, coagulopathy, GI bleeding, hepatic failure, infection, cardiac arrhythmias — Harrison's; Washington Manual

General Supportive Care

• Thiamine: 100–500 mg IM/IV before any glucose administration (prevents Wernicke encephalopathy); then 100 mg PO daily × 1 week+
• Multivitamins including folic acid
• Nutrition: balanced diet as tolerated
• IV fluids: NOT routine — most patients are normohydrated or mildly overhydrated; only give for haemorrhage, persistent vomiting, or diarrhoea
• Electrolyte correction: magnesium, potassium, phosphate as needed — Harrison's; Rosen's

Pharmacotherapy

First-Line: Benzodiazepines

• Chlordiazepoxide 25–100 mg TID, tapered over 3–6 days, OR
• Diazepam 30 mg daily tapered over 5 days, OR
• Lorazepam 1–2 mg TID tapered over 3–6 days

• Diazepam 10 mg IV q5–20 min until control achieved, OR
• Lorazepam 2–4 mg IV q15–20 min

Adjuncts & Alternatives

• GABA-A agonist; effective for refractory or severe AWS and benzodiazepine-resistant cases
• Two 2023–2024 meta-analyses (PMID 37060631, PMID 37923363) support phenobarbital in the ED as an effective alternative, with reduced ICU admission and reduced need for intubation compared to benzodiazepine-only approaches
• Growing interest in phenobarbital as first-line or add-on especially in ED/ICU settings

• Reserved for refractory DTs in the ICU; a 2025 systematic review (PMID 39415533) supports its use for refractory AWS when benzodiazepines fail; requires mechanical ventilation

• Alpha-2 agonist; controls autonomic symptoms but does not prevent seizures and does not target GABA/glutamate systems; generally not recommended as sole agent; may mask withdrawal signs — Washington Manual

• Some units recommend loading for patients with untreated epilepsy or seizures despite adequate benzodiazepine loading; effective as an alternative in mild-moderate withdrawal in some guidelines — Maudsley

Seizure Management

• Benzodiazepines (lorazepam IV) are first-line for active seizures
• AEDs are not indicated for typical alcohol withdrawal seizures after the event
• Long-acting benzodiazepines (diazepam) are recommended for prophylaxis in those with prior seizure history
• Always exclude hypoglycaemia; give thiamine before glucose
• Head CT indicated for first-time or focal seizures; partial/focal seizures require admission
• Status epilepticus: treat aggressively, likely requires ICU — Rosen's; Maudsley

Setting of Care

Outpatient/Community Detoxification (appropriate when all are met):

• Reliable, motivated patient; medically and psychiatrically stable
• No prior DTs or withdrawal seizures
• No complex comorbidities; not pregnant
• Responsible carer available 24 h; daily professional review; contingency plan in place
• Prescribe ≤1–2 days of medication at a time; admit if symptoms escalate

Inpatient Required When:

• Regular consumption >30 units/day or SADQ score >30
• Prior seizures or DTs
• Concurrent benzodiazepine use or polysubstance use
• Comorbid mental/physical illness, pregnancy, homelessness
• Failed community detox; minor or elderly patient — Maudsley Prescribing Guidelines

ICU Criteria:

• Haemodynamic instability, persistent fever or hypothermia, rhabdomyolysis, renal insufficiency, severe electrolyte/acid-base disturbance, frank DTs, status epilepticus, severe comorbidities — Rosen's

Long-Term Treatment of Alcohol Use Disorder (AUD)

Summary Algorithm

Heavy drinker stopping alcohol
         ↓
Physical exam + labs + CIWA-Ar score
         ↓
Thiamine 100–500 mg IM/IV → electrolyte correction → nutrition
         ↓
CIWA-Ar < 8        CIWA-Ar 8–15           CIWA-Ar > 15 / DTs
   ↓                    ↓                        ↓
Supportive care    Benzodiazepine PO        IV benzodiazepines
                   symptom-triggered        (diazepam or lorazepam)
                   taper 3–5 days           ± phenobarbital
                   Outpatient if safe       ICU admission
                                            (propofol if refractory)
         ↓
Seizures → lorazepam IV (AEDs not needed long-term)
         ↓
Recovery → AUD pharmacotherapy + psychosocial support