Alcohol Withdrawel Treatment

CIWA-Ar Protocol (0–67 points)
First-line guide

0–9 (mild): supportive care; consider PRN benzodiazepine if symptoms evolve.
10–19 (moderate): medication indicated — symptom-triggered benzodiazepines preferred.
≥20 (severe): high seizure/DT risk — aggressive therapy, consider ICU, phenobarbital ± adjuncts.
Reassess CIWA every 1–2 hours. CIWA is unreliable in delirious/non-verbal ICU patients — use a sedation target (e.g., RASS) with a fixed/weight-based regimen.

Clinical context	First-line	Escalate / Add-on	Monitoring notes
Mild (CIWA 0–9), stable, outpatient or floor	Oral benzodiazepine PRN (chlordiazepoxide or lorazepam)	Short oral taper if symptoms persist or trend upward	Re-score q2–4h; thiamine, fluids, electrolytes
Moderate (CIWA 10–19), ED/floor	Symptom-triggered benzodiazepines (PO/IV)	If high needs/poor response: phenobarbital adjunct; clonidine for autonomic symptoms	Frequent CIWA; watch oversedation/hypoxia; correct Mg/K/PO4
Severe (CIWA ≥20), seizures, DTs, or rapid escalation	High-dose benzodiazepine strategy or phenobarbital-based regimen; ICU consult	Adjuncts: dexmedetomidine for agitation; haloperidol for psychosis (with benzo/barb); propofol if intubated	ICU-level monitoring pulse-ox ± capnography; use RASS-based titration

Benzodiazepines (first-line)

General: Symptom-triggered dosing guided by CIWA-Ar preferred when feasible.

Diazepam (PO/IV): 10–20 mg q1–2h PRN until calm/lightly drowsy (typical early cumulative 20–60 mg). In monitored settings for severe agitation: 5–10 mg IV q5–10 min to effect.
Lorazepam (PO/IV/IM): 2–4 mg q1–2h PRN; slower onset, safer in liver disease/elderly; typical early cumulative 8–16 mg.
Chlordiazepoxide (Librium) (PO): 25–50 mg q1–2h PRN; or fixed taper e.g., Day 1 total 50–100 mg, then 25–50 mg q6h; taper over 3–5 days.

Notes: Prefer long-acting agents (diazepam/chlordiazepoxide) for smoother course; choose lorazepam if significant hepatic dysfunction. Monitor respiration and mental status closely.

Phenobarbital (alternative/adjunct; refractory AWS)

Loading (IV): 10–15 mg/kg total, divided as 130–260 mg IV boluses q20–30 min to effect (stop with adequate sedation/adverse effects).
Maintenance: ~1–3 mg/kg/day (e.g., 60–120 mg IV/PO q12h) with clinical reassessment.
Use when: Severe AWS, benzodiazepine-resistant cases, or contraindication to benzos. Can be monotherapy protocols or combined with lower benzo doses.
Caution: Synergistic respiratory depression with benzos — use in monitored settings; avoid if significant respiratory compromise without airway support.

Dexmedetomidine (Precedex) — adjunct for agitation/autonomic surge

Infusion: Start 0.2–0.3 mcg/kg/hr; titrate ~0.7–1.2 mcg/kg/hr by agitation/hemodynamics. Avoid bolus.
Role: Reduces sympathetic hyperactivity and benzo needs in ICU. Does not prevent seizures — always pair with benzo and/or phenobarbital.
Watch: Bradycardia, hypotension; continuous monitoring required.

Propofol (ICU; intubated or impending airway)

Infusion: 5–10 mcg/kg/min, titrate as needed (often 10–50 mcg/kg/min).
Role: Rapid control of severe agitation/DTs in intubated patients; anticonvulsant properties.
Notes: Requires airway/ICU monitoring; monitor BP and triglycerides with prolonged use.

Antipsychotics (adjunct only; NOT monotherapy)

Haloperidol 2.5–5 mg IV/IM q4–6h PRN for severe hallucinations/psychosis; consider lower doses in elderly. Always with benzo/barb coverage (do not treat AWS pathophysiology alone; may lower seizure threshold).
Monitor: QTc/EPS; correct K/Mg first.

Autonomic symptom control: Clonidine

Clonidine 0.1–0.2 mg PO q6–8h (typical total 0.2–0.8 mg/day) or transdermal 0.1–0.3 mg/24h weekly.
Role: Controls tachycardia, hypertension, diaphoresis as adjunct. Not antiepileptic; not monotherapy for AWS.
Hold for: Hypotension, bradycardia.

Outpatient/mild adjuncts: Gabapentin, Carbamazepine, Valproate

Gabapentin 300 mg PO TID, titrate to 600 mg TID (renal dosing). Helps mild–moderate symptoms; may reduce benzo needs.
Carbamazepine 200 mg PO QID (day 1), then TID (days 2–3), then BID (days 4–5) — for selected mild–moderate cases; not for severe/DTs.
Valproate 250–500 mg PO/IV TID as adjunct in selected patients; avoid in liver disease, pregnancy, thrombocytopenia.

Supportive therapy (give thiamine before glucose when possible)

Thiamine:
• Prophylaxis (no strong Wernicke’s suspicion): 100 mg IV/IM once daily for 3–5 days, then 100 mg PO daily.
• Suspected/confirmed Wernicke’s: 200–500 mg IV every 8 hours for 2–3 days, then 250 mg IV/IM daily for 3–5 days, then 100 mg PO daily.
• Timing: Give thiamine before glucose when feasible. If hypoglycemic, give glucose immediately and administer thiamine as soon as possible thereafter.

Electrolytes/Fluids: Replete Mg (e.g., 1–2 g IV to keep > 2 mg/dL), K (target ~4–5 mEq/L), phosphate (target normal range), maintain euvolemia; add folate and multivitamins.

Specialist-guided adjunct: Ketamine (selected refractory cases)

Ketamine: infusion ~0.1–0.3 mg/kg/hr (± small bolus) to reduce benzo needs in refractory agitation; ICU monitoring required.
Note: Always combine with GABAergic therapy (benzodiazepine/phenobarbital). Monitor BP/HR and emergence phenomena.

Implementation tip: If CIWA cannot be obtained reliably (e.g., intubated/delirious), switch to a fixed-dose benzodiazepine or phenobarbital protocol with a sedation target (RASS), plus supportive care and seizure prophylaxis.