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 to calculate FAST (Fast Alcohol Screening Tool) score. This will guide what initial intervention is required e.g. advice only, leaflets, referral to addiction liaison, drug intervention.
Also consider alternative diagnoses such as delirium, encephalopathy, traumatic brain injury especially if symptoms atypical or prolonged (≥5 days since last alcohol).
Be aware of patients with co-morbidities or other clinical characteristics presenting with features of alcohol withdrawal especially:
- Patients with evidence of liver disease, especially jaundice, encephalopathy
- Patients with chronic obstructive pulmonary disease (COPD), pneumonia, cerebrovascular disease, reduced GCS, elderly >70 years, head injury, pregnancy. See below for management advice.
Use the flowchart below to assess whether patient is at high risk of withdrawal or not. The Glasgow Modified Alcohol Withdrawal Scale (GMAWS) sheet can be found on NHSGGC StaffNet / Clinical Info / Clinical Guideline Directory (link only active if accessing via NHS computer) and search for 'Alcohol'.
If 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).
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).
Baseline treatment regimen
- 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. If after 24 hours no additional symptom triggered treatment has been required, or if after ≥48 hours of treatment GMAWS is <4, reduce as follows:
- Diazepam oral 15mg 6 hourly for 24 hours then
- 10mg 6 hourly for 24 hours then
- 5mg 6 hourly for 24 hours then
- 5mg 12 hourly 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
- Patients with evidence of liver disease especially jaundice or encephalopathy - use lorazapam oral (in a symptom triggered fashion) 1-2mg (up to 12mg in 24 hours, when senior review is required, ST3 or above)
- Patients with other co-morbidity (i.e. COPD, pneumonia, cerbrovascular disease, reduced GCS, head injury) or who is >70 years of age - use lorazepam oral as above or diazepam at 50% of standard GMAWS dose.
- Pregnant patients - use diazepam at 50% of standard GMAWS dose with senior medical review if >30mg required in 24 hours.
- Review diazepam dose if patient is excessively drowsy.
- Request senior medical review (ST3 or above) if patient requires >120mg diazepam in 24 hours or if patient is still requiring full dose treatment 96 hours after last alcohol ingestion. Diazepam 120mg is not expected to be problematic over 24 hours in uncomplicated patients.
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. Give:
- Diazemuls IV up to 40mg over the first 30 minutes (max rate 2mg/minute; flumazenil should be made available). See section below on 'Patients unable to tolerate oral mediciation'.
- Adjunctive therapy with haloperidol* IM 2-5mg in the first instance and response assessed.
- Consultation regarding intensive care support may be necessary in extreme situations.
*Haloperidol contraindications include: patients with prolonged QTc interval and in combination with other drugs that prolong QTc interval. Prior to treatment (or as soon as possible afterwards if the patient is too agitated) record an ECG to check QT interval. Ensure modifiable risk factors for QTc interval prolongation are minimised e.g. electrolyte abnormalities and discontinue other drugs known to prolong QTc interval if possible. A list of drugs that can prolong QT interval can be found at http://crediblemeds.org/ and further information can also be found in the Medicines Update Extra (MUE 02) drug induced prolongation article available at www.ggcprescribing.org.uk.
Unable to tolerate oral medication
- An alternative to oral diazepam or lorazepam in these patients may be IV diazemuls or lorazepam at 50% of the oral dose in the first instance (see above), and then assess response.
- Intravenous benzodiazepines should be given by experienced members of medical (FY2 or above) or nursing staff who have completed the appropriate competency training to administer IV sedation.
- Closely observe for signs of over-sedation with regular observations.
- Exceptional patient groups (see above), patients with severe withdrawal and patients requiring parenteral sedation as described above require close monitoring (NEWS) ideally with one-to-one nursing care.
- 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.
- On discharge patients should not be given benzodiazepine. Chlordiazepoxide is the recommended benzodiazepine for community use.
- Approximate oral benzodiazepine dose equivalence:
- Diazepam 10mg = lorazepam 1mg = chlordiazepoxide 25mg
Content last reviewed August 2020