Alcohol withdrawal

Background

Risk Factors for Severe Withdrawal

• Severity predicted by PAWSS scale: if score ≤3 can manage as outpatient
• History of alcohol withdrawal, especially if previously severe (e.g. delirium tremens)
• Age
• Alcohol tolerance
• Concurrent sedative medications
• Major medical comorbidities
• Drinking all day long

Clinical Manifestations

• 6 to 12 hours after last drink: shaking, headache, sweating, anxiety, nausea, or vomiting
• 12 to 24 hours after last drink: confusion, hallucinosis (with awareness of reality), tremor, or agitation
• 24 to 48 hours after last drink: seizures
• 48 hours after last drink: delirium tremens, high blood pressure, and fever
  • Can persist anywhere from 4 to 12 days

Investigations

• Monitor electrolytes and extended electrolytes for refeeding syndrome

Management

• Given the balance of risks (minimal) and benefits (potentially large), almost all patients treated for alcohol withdrawal should receive supplemental thiamine
  • Standard: 250 mg IM/IV q24h x3d
  • High-dose: 500 mg IV q8h x3

Inpatient Management

Benzodiazepine Protocols

• If history of seizures: diazepam 20mg q1h x3 doses before starting CIWA
• Can use diazepam, lorazepam (if liver disease), or Chlordiazepoxide
• Start CIWA-Ar (Clinical Institute Withdrawal Assessment - Alcohol revised) q1h
  • CIWA-Ar 10-20
    • First-line: diazepam 10mg PO/IV q1h
    • Liver dysfunction: lorazepam 2mg PO/IV/IM q1h
    • Liver failure, age >60, chronic opioid use, acute respiratory illness: lorazepam 1mg PO/IV/IM q1h
  • CIWA-Ar >20
    • 1L NS bolus over 30 minutes followed by 200mL/h
    • First-line: diazepam 20mg PO/IV q1h
    • Liver dysfunction: lorazepam 4mg PO/IV/IM q1h
    • Liver failure, age >60, chronic opioid use, acute respiratory illness: lorazepam 2mg PO/IV/IM q1h
  • Discontinue CIWA-Ar protocol after two consecutive scores <10

Phenobarbital Protocols

General Protocol

• Load phenobarbital 10 mg/kg IV up front over 30min (if has not received significant benzodiazepines)
• Then give 130-260 mg IV prn for mild to severe withdrawal symptoms
• Titrate to effect; there is no maximum dose
• Maintenance with 100-200 mg PO/IM q1h prn

CAMH protocol

• Loading: phenobarbital 120 mg po q1h until phenobarbital loading effect score is 3 to 4, then stop loading
• Maintenance: phenobarbital 60 mg po qid
• Taper:
  • Decrease by 30 mg each day from a starting dose of phenobarbital 60 mg po qid
  • 60/60/60/60, 60/30/60/60, 60/30/30/60, 60/30/30/30, 30/30/30/30, 30/–/30/30, 30/–/–/30, 30/–/–/–, stop
  • Takes 8 days
• Phenobarbital loading effect scale
  • Nystagmus: absent (0); present on extension of lateral gaze (1); easily elicited and sustained (2); coarse, sustained nystagmus (3)
  • Dysarthria: absent (0); minor slurring of some words (1); moderate slurring frequently (2); severe slurring, unintelligible (3)
  • Ataxia: absent (0); mildly unsteady on tandem gait (1); moderately unsteady on regular gait (2); needs support on regular gait (3)
  • Emotional lability: normal, as before loading (0); some mood change (1); obvious mood change, inappropriate (2); uninhibited, mood swings (3)

Seizures

• Lorazepam prn until terminates
• After seizure, lorazepam 2mg IV once to prevent recurrence

Outpatient Management

• For patients at low risk of complicated withdrawal, office-based management can be considered
  • Start on Monday or Tuesday, unless there is weekend coverage for the clinic
  • Assess the patient daily
• Typically use diazepam per schedule below, with thiamine 100 mg po daily for 5 days

Schedule	Day 1	Day 2	Day 3	Day 4
Rigid	10 mg qid	10 mg tid	10 mg bid	10 mg qhs
Flexible	10 mg q4-6h prn	10 mg q6-8h prn	10 mg q12h prn	10 mg qhs prn
Front-loaded	20 mg q2-4h until sedated, followed by 10 mg q4-6h prn (max 60 mg daily)	10 mg q4-6h prn (max 40 mg)	10 mg q4-6h prn (max 40 mg)	none

• Symptoms to trigger prn doses in the above schedules include heart rate >100, DBP >90 mmHg, or signs of withdrawal
• Front-loaded schedules often need very little medication after the load