Refer to the clinical institute withdrawal assessment for alcohol scale (CIWA-Ar)

• A validated 10-item assessment tool used to monitor the severity of withdrawal and monitor pharmacotherapy

   ○ A score of ≤ 8 corresponds to mild withdrawal

   ○ A score between 9 and 15 corresponds to moderate withdrawal

   ○ A score of more than 15 corresponds to severe withdrawal and at increased risk of seizures and delirium tremens

Supportive care

• Intravenous fluids

• Correct any electrolyte abnormalities

• Thiamine 100 mg intravenously/enterally daily

   ○ Administer before glucose administration to prevent precipitation of Wernicke’s encephalopathy

• Multivitamin daily (source of folate)

• Avoid phenothiazines and haloperidol, as both may lower the seizure threshold

Benzodiazepine pharmacotherapy

• Fixed dose regimens

   ○ Administered at specific intervals with additional doses given as needed

   ○ Chlordiazepoxide 50–100 mg enterally every 6 h for 1 day, 25–50 mg every 6 h for 2 days then continue to taper for a total of 7 days

   ○ In patients with significant liver dysfunction, lorazepam or oxazepam may be preferred

   ○ This regimen is useful in patients at high risk of major withdrawal or history of withdrawal seizures or delirium tremens

• Loading dose strategy

   ○ Diazepam 10–20 mg intravenously/enterally initially to provide sedation

   ○ Titrate additional doses every 5–15 min until goal achieved

     ■ Can double the dose until the appropriate level of sedation is achieved

     ■ Maximum dose is not clear; some experts have utilized diazepam doses above 200 mg

   ○ Then allow the drug level to taper through metabolism

• Symptom-triggered regimens

   ○ Administered only when the CIWA-Ar score is ≥ 9. May administer with a lower threshold (i.e., CIWA-Ar score < 9) if there is a history of withdrawal seizures

     ■ Administer diazepam 5–10 mg IV/enterally initially. Measure the CIWA-Ar score 1 h after the initial and each subsequent dose of diazepam. Adjust dose based on severity of symptoms

     ■ Alternative may be chlordiazepoxide 25–50 mg intravenously/enterally every hour as needed

   ○ This approach may result in less total medication and more rapid detoxification

Other pharmacotherapy for alcohol withdrawal symptoms

• Phenobarbital

• Ethanol (enteral)

Adjuvant pharmacotherapy

• Sympatholytics

   ○ β-adrenergic blockers, dexmedetomidine, or clonidine may be utilized in conjunction with benzodiazepines in patients with coronary artery disease who may not tolerate adrenergic excess

• Benzodiazepine-refractory delirium tremens

   ○ Consider propofol pharmacotherapy, as it agonizes GABA-A receptors and antagonizes NMDA receptors. Patient must have a protected airway

   ○ Phenobarbital can be used as an alternative

Anticonvulsant pharmacotherapy for status epilepticus (uncommon—consider alternative etiology)