Management of Alcohol Withdrawal Syndrome

Assessment / monitoring

The likelihood of withdrawal reaction is indicated from a patient's history. Use the alcohol misuse assessment form to establish patient's alcohol consumption and calculate an alcohol screening score using the "Audit PC" tool (Step 1: Determine Alcohol History) below. Referral to alcohol liaison should be made if "Audit PC" score indicates that the individual is drinking at harmful / hazardous / dependent levels. Also consider alternative diagnoses such as delirium, encephalopathy, traumatic brain injury especially if symptoms atypical or prolonged (≥5 days since last alcohol). 

• Step 1: Determine Alcohol History

Use the tool below (Step 2: Determine Treatment Option) to assess whether the patient is at high risk of withdrawal and the treatment option for the management of alcohol withdrawal syndrome.

• Step 2: Determine Treatment Option

N.B. Be aware of patients with co-morbidities or other clinical characteristics presenting with features of alcohol withdrawal especially:

• Actual or suspected head injury
• Hepatic impairment (patients with elevated bilirubin or prothrombin time who are at risk of benzodiazepine accumulation)
• Other co-morbidities where the patient is at risk of over-sedation or respiratory depression e.g. respiratory or cerebrovascular disease, reduced Glasgow Coma Scale, elderly (>65years), creatinine clearance (CrCl) <20ml/min. See below for management advice.

If the patient is a chronic alcohol misuser or has hazardous / harmful alcohol intake then also assess for risk of Wernicke's encephalopathy (see Vitamin prophylaxis and treatment of Wernicke's encephalopathy).

General management

For patients at high risk of alcohol withdrawal see below for fixed dose diazepam treatment regime. There may be certain groups of patients in whom an alternative choice or route of benzodiazepine should be considered (see below for further information).

Fixed dose treatment

• For patients at high risk of alcohol withdrawal give a fixed dose of diazepam. In the initial 24 hours prescribe: diazepam oral 20mg 6 hourly.
• For patients scoring regularly on symptom triggered treatment, despite initial fixed dose of diazepam (20mg 6hourly), then increase the regular diazepam dose to 25-40mg four times per day (based on clinical judgment depending on factors including units of alcohol consumed, history of severe withdrawal and current presentation).
• Patients previously treated for severe alcohol withdrawal syndrome with diazepam 20mg four times per day who required regular additional symptom triggered treatment may require an initial fixed dose of diazepam up to 40mg four times per day. Contact alcohol liaison for advice if required.
• If patient is stable and has not has not required additional symptom triggered treatment in past 24 hours, reduce diazepam dose as follows:
  • Reduce diazepam by 5mg four times a day until on 15mg four times a day then
  • 15mg four times per day for 24 hours then
  • 10mg four times per day for 24 hours then
  • 5mg four times per day for 24 hours then
  • 5mg two times per day for 24 hours
• For patients unable to tolerate diazepam via the oral route or presenting with severe alcohol withdrawal, see guidance below.

Exceptional patient groups: symptom triggered treatment only

Use lorazapam oral (in a symptom triggered fashion - dose dependent on GMAWS score) 1-2mg (up to 12mg in 24 hours, when senior review is required) in the following patient groups:

• Actual or suspected head injury
• Hepatic impairment (patients with elevated bilirubin or prothrombin time who are at risk of benzodiazepine accumulation)
• Other co-morbidities where the patient is at risk of over-sedation or respiratory depression e.g. respiratory or cerebrovascular disease, reduced Glasgow Coma Scale.

Use diazepam at 50% of standard GMAWS dose in the following patient groups:

• Elderly (>65 years)
• CrCl <20ml/min

Review

• Review diazepam dose if patient is excessively drowsy.
• Request senior medical review if patient requires >120mg diazepam (or equivalent) in 24 hours. 

N.B. Lorazepam has a slower onset of peak effect but ultimately a more rapid elimination.

Severe alcohol withdrawal

These patients can exhibit aggressive / uncontrollable / dangerous behaviour. Where high dose oral benzodiazepines are inadequate, high dose parenteral benzodiazepine (e.g. 40mg diazepam) may be required. If adjunctive therapy with haloperidol is required, refer to ADTC 220 Rapid Tranquillisation: Adults (age 18-64 years) in Acute Hospital Wards on AthenA.

Unable to tolerate oral medication 

• Patients unable to tolerate oral medication may receive intravenous therapy as an alternative at 50% of the oral dose in the first instance, and response assessed.
• See below for benzodiazepine dose equivalences.

Monitoring

• Closely observe for signs of over-sedation with regular observations.
• Exceptional patient groups (see above), patients with severe withdrawal and patients requiring IV / IM sedation as described above require close monitoring (NEWS2).

Other information

• Patients may require to be woken for continuing assessment.
• Co-existing illness may affect score - seek medical advice if in doubt.
• Fixed dosing and symptom triggered dosing must be no less than 1 hour apart.
• Patients should not be routinely discharged until detox process is complete.
• Approximate oral benzodiazepine dose equivalence:
  • Diazepam oral 10mg = lorazepam oral 1mg
• IM / IV benzodiazepine dose equivalence is half the oral dose. For example:
  • Diazepam oral 20mg four times daily = diazepam IM / IV 10mg four times daily.
  • Lorazepam oral 2mg four times daily = lorazepam IM / IV 1mg four times daily.