EMed

Alcohol withdrawal - standard treatment

Applies to those admitted to wards NOT to CDU where CIWA is the preferred choice.

When to treat

  1. Obvious withdrawal: i.e. CIWA –Ar Score > 10, autonomic hyperactivity (e.g., sweating or HR> 100), ↑ hand tremor, psychomotor agitation
  2. Not in withdrawal but a clear history (i.e. drinking >10 units per day, previous withdrawal)
  3. Patient in ED awaiting medical admission
  4. Patients in CDU/awaiting CDU who are not suitable for symptom-triggered detoxification

How to treat

Benzodiazepines orally in reducing doses over five days.

Please remember: Diazepam 10 mg = chlordiazepoxide 25mg = lorazepam 1mg.

Chlordiazepoxide and lorazepam regimens
Day Chlordiazepoxide dose Lorazepam dose
1 Regular 10 - 40 mg qds 1 - 2mg tds R
e
v
i
e
w

D
a
i
l
y
prn 10 - 40mg 2-hrly 1mg 2-hrly
  Daily Max 250mg in 24hr 8mg
2   10 - 40mg qds ± PRN 1 - 2mg tds
3   10 - 30mg qds ± PRN 1 - 2 mg tds
4   10mg qds ↓ by 1mg per day
5   10mg bd ↓ by 1mg per day
6     ↓ by 1mg per day
7     ↓ by 1mg per day
8      
  • Base initial benzodiazepine dose on severity of withdrawal symptoms in previous 24 hours, or severity of alcohol dependence. Adjust the dose daily according to response
  • Reduce dose in elderly, frail subjects or adjusted according to body mass
  • Liver disease: Patients with abnormal liver enzymes but no clinical evidence of liver failure and normal serum bilirubin, albumin and prothrombin time are suitable for Chlordiazepoxide. Consider lorazepam if liver failure
  • See ‘Symptom-triggered’ guideline for front loaded detoxification used in CDU only
  • Print version

Adjunctive treatment

Wernicke-Korsakoff Syndrome

Prevention: Pabrinex 1 pair Amps I and II IV daily for 3-5 days followed by oral thiamine 300mg od.

Treatment (i.e. any unexplained confusion): Pabrinex 2 pairs Amps I and II (total 4 vials) IV TID for 3 days and continue 1 pair Amps I and II daily if improving.

Note: Pabrinex carries a CSM warning – rare anaphylaxis risk.

Psychotic symptoms (occurs in Delirium Tremens)

  • Adjust Chlordiazepoxide dose
  • Haloperidol:
    • No liver disease: 5mg PO or IM 4-hrly if required. Max dose 30mg/24-hr
    • Liver disease 0.5mg PO or IM 2-hrly if required. Max dose 2mg /24hrs
  • Note Diazepam 10mg iv over >5mins or Lorazepam iv may be given in severe agitation

Acutely Disturbed/Violent Behaviour

Monitoring

  1. Vital Signs
  2. Level of Arousal
  3. Severity of withdrawal (e.g. using CIWA-Ar scale)
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Be wary of dehydration, hypoglycaemia, delirium due to infection, head injury.

Drowsiness is not a feature of alcohol withdrawal. Nursing staff should omit dose of Chlordiazepoxide if patient is drowsy and look for other causes.

Content by Dr Íomhar O' Sullivan, Prof Eugene Cassidy. Last review Dr ÍOS 26/02/24.