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Management of Severe Alcohol Withdrawal
Management of Severe Alcohol Withdrawal
Defined as:
Defined as:
Requiring IV benzodiazepenes
Requiring CIWA > q4h
High risk of seizures
Key management points:
Key management points:
UHN/TWH CIWA orderset is available
IV benzodiazepenes for individuals with aLOC, cannot tolerate PO intake
Patients with high withdrawal scores may require:
Maintenance benzodiazepenes
More frequent CIWA (i.e. - q1h)
High dose thiamine is recommended for patients with possible Wernicke's/Korsakoff's
Always discuss anti-craving medication if/when patient is able and willing to engage. Offer RAAM referral.
Treatment Options for Alcohol Withdrawal
Treatment Options for Alcohol Withdrawal
Lorazepam
Lorazepam
PO/SL/IV administration
2-4 mg PO/SL/IV q1h prn
Diazepam
Diazepam
PO/IV administration
Loading dose: 10-20mg q20min x 3 doses (total of 30-60mg)
10 - 20mg PO q1h prn
5-10 mg IV q20 min PRN as loading dose, then can change to q1h stable dose IV administration if PO not tolerated
Thiamine
Thiamine
Dosing: 100mg IV/IM/PO x 1, then daily x 3
If evidence of Wernicke's/Korsakoff's: 500mg PO/IV TID until symptoms resolve (remember to give thiamine before glucose-containing fluids to avoid precitipating Wenicke's encephalopathy)
Anti-Craving Medications
Anti-Craving Medications
Naltrexone 25 mg PO daily - can titrate up to 100mg PO daily as an outpatient
Best option for patients without liver dysfunction
Should not be used if patient has concomitant opiate use
Acamprosate 333 - 666mg PO TID
Best option for patients with liver dysfunction
Not recommended if patient is not abstinent from alcohol
Gabapentin 300mg PO TID - can titrate up to 900mg PO TID as an outpatient
Has been demonstrated to have similar efficacy to Naltrexone
Last Updated: October 2021
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