Alcoholics are often deficient in electrolytes or minerals, including thiamine, folate, and magnesium (although replacing magnesium makes no difference in clinically meaningful outcomes) (level of evidence [LOE]: 1, double-blind randomized controlled trial).11 All patients being treated for alcohol withdrawal should be given 100 mg of thiamine immediately and daily (LOE: 3; insufficient evidence from randomized controlled trials to guide clinicians in the dose, frequency, route, or duration of thiamine treatment for prophylaxis against or treatment of WKS due to alcohol abuse).4 Thiamine should be given before glucose containing fluids, to avoid the risk of precipitating Wernicke syndrome (LOE: 3).12
Assess the severity of the withdrawal
Once a diagnosis of alcohol withdrawal is made, complete an assessment of the severity of withdrawal and the risk of complications. The best validated tool is the Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) symptom scale (Figure 1).10 This instrument rates 10 withdrawal features; it takes only a few minutes to administer and may be repeated when re-evaluation is necessary. CIWA-Ar scores of ≤8 are suggestive of mild withdrawal symptoms, while those ≥15 confer an increased risk for confusion and seizures.
CIWA-Ar is reliable, brief, uncomplicated, and clinically useful scale that can also be used to monitor response to treatment. It offers an increase in efficiency over the original CIWA-A scale, while retaining clinical usefulness, validity, and reliability. It can be incorporated into the usual clinical care of patients undergoing alcohol withdrawal and into clinical drug trials of alcohol withdrawal (strength of recommendation [SOR]=A].5,13
Patients experiencing more serious withdrawal (with CIWA-Ar scores >8) should receive pharmacotherapy to treat their symptoms and reduce their risk of seizures and DTs (SOR=A).14
Benzodiazepines are the mainstay of treatment in alcohol withdrawal (number needed to treat [NNT]=17; data from large meta-analysis of 6 prospective, placebo-controlled trials) (SOR=A).10,14,16 Like alcohol, these agents magnify GABA’s effect on the brain. Benzodiazepines are cross-tolerant with alcohol; during withdrawal from 1 agent, the other may serve as a substitute. Benzodiazepines also reduce the incidence of DTs and seizures (Table 1).5,14
The problem. In our small community hospital, prior to the development of a clinical practice guideline, admissions for “inpatient alcohol detoxification” were among our top 5, with a select few patients making multiple, repeat visits. Additionally, we had no standardized, consistent strategy for initial emergency room evaluation; frequent early discharges against medical advice; multiple readmissions; infrequent and inconsistent entry into our outpatient Alcohol and Substance Abuse Program; and no existing process for primary care outpatient follow-up. We found ourselves in a situation where we were essentially enabling our patients in a destructive behavior. With no formal policy or guidelines, physicians tended to follow the path of least resistance: repeated short-stay admissions with limited therapeutic benefit.
The process. Our initial goal was to develop a standardized policy in an attempt to minimize the number of admissions of mild-to-moderate, uncomplicated alcohol withdrawal patients. Many of our patients are at low risk for serious complications, and we hoped to triage such individuals to an outpatient treatment setting. To organize the thought process, a flowchart was developed and refined. By incorporating current evidence, a clinical practice guideline was developed.
Evidence-based algorithm. We developed an evidence-based algorithm, Outpatient Treatment for Alcohol Detoxification (Figure 2), which uses a gradually tapering regimen, and allows providers to prescribe the medication they feel most appropriate given the clinical situation.
Results. In the 12 months since implementation of our clinical practice guideline, total alcohol-related admission decreased from 4 to 5 per month to only 1 during the entire period; furthermore, no patients treated with our guidelines were subsequently hospitalized for complications of alcohol withdrawal.
The most commonly used benzodiazepines are diazepam (Valium), chlordiazepoxide (Librium), and lorazepam (Ativan). All appear to be equally efficacious in treating alcohol withdrawal symptoms (LOE: 1; randomized controlled trial).
Longer-acting agents, such as chlordiazepoxide or diazepam, contribute to an overall smoother withdrawal course with lessened breakthrough or rebound symptoms, but they may also lead to excess sedation for patients with hepatic dysfunction.17-20 Shorter-acting benzodiazepines, such as oxazepam (Serax), may result in greater discomfort and more discharges against medical advice, because alcohol withdrawal symptoms tend to recur when serum benzodiazepine levels drop.
Pharmacologic treatment of alcohol withdrawal
|Benzodiazepines||Remain drug of choice for acute alcohol withdrawal14||A|
|Highly significant decrease in seizures and delirium|
|Risk reduction 7.72 seizures/100 patients, 4.9 DTs/100 patients20|
|Some abuse potential|
|Carbamazepine||Well-documented anticonvulsant activity; prevents seizures from alcohol Withdrawal||A|
|No abuse potential|
|Especially good for those with multiple previously treated withdrawals22|
|Relative risk of first drink after withdrawal in benzodiazepine group over 3 times higher than carbamazepine22|
|If carbamazepine-treated patients relapse, they drink less than benzodiazepine-treated patients [absolute risk reduction=4]22|
|Valproic acid||Significantly affects the course of acute alcohol withdrawal and reduces need for treatment with a benzodiazepine [absolute risk reduction=4]24||A|
|Use limited by side effects which mimic alcohol withdrawal|
|Wide therapeutic range makes unintentional overdose uncommon|