Alcohol withdrawal

Clinical Institute Withdrawal Assessment for Alcohol scale, revised version (CIWA-Ar) or Glasgow Modified Alcohol Withdrawal Scale (GMAWS)

Use a validated scoring system, such as CIWA-Ar ( Clinical Institute Withdrawal Assessment of Alcohol, revised Opens in new window) or GMAWS ( Glasgow Modified Alcohol Withdrawal Scale Opens in new window), with your clinical judgement to assess all patients with alcohol withdrawal, to gauge severity, guide management, and monitor patients during treatment.[1]National Institute for Health and Care Excellence. Alcohol-use disorders: diagnosis and clinical management of alcohol-related physical complications. April 2017 [internet publication]. https://www.nice.org.uk/guidance/cg100 [2]Royal College of Physicians. Alcohol dependence and withdrawal in the acute hospital. June 2012 [internet publication]. https://www.rcplondon.ac.uk/guidelines-policy/alcohol-dependence-and-withdrawal-acute-hospital [3]Bråthen G, Ben-Menachem E, Brodtkorb E, et al. Chapter 29: alcohol-related seizures. In: Gilhus NE, Barnes MP, Brainin M, eds. European handbook of neurological management. 2nd ed, vol 1. Oxford, UK: Blackwell publishing; 2011:429-36. https://www.eaneurology.org/fileadmin/user_upload/guidline_papers/EFNS_guideline_2011_Alcohol-related_seizures.pdf

• Check local protocols for recommendations on which scale to use and cut-off values for mild, moderate, and severe withdrawal. GMAWS is an alternative to CIWA-Ar for use in an acute hospital setting.[33]McPherson A, Benson G, Forrest EH. Appraisal of the Glasgow assessment and management of alcohol guideline: a comprehensive alcohol management protocol for use in general hospitals. QJM. 2012 Feb 10;105(7):649-56. https://www.doi.org/10.1093/qjmed/hcs020 http://www.ncbi.nlm.nih.gov/pubmed/22328545?tool=bestpractice.com

• Assign a score to each item, based on your observations and the patient’s answers to structured questioning.

  • Speak slowly and clearly; reword questions if needed.

• Add up the number of points to reach a total.

Use the total CIWA-Ar or GMAWS score to:[2]Royal College of Physicians. Alcohol dependence and withdrawal in the acute hospital. June 2012 [internet publication]. https://www.rcplondon.ac.uk/guidelines-policy/alcohol-dependence-and-withdrawal-acute-hospital [3]Bråthen G, Ben-Menachem E, Brodtkorb E, et al. Chapter 29: alcohol-related seizures. In: Gilhus NE, Barnes MP, Brainin M, eds. European handbook of neurological management. 2nd ed, vol 1. Oxford, UK: Blackwell publishing; 2011:429-36. https://www.eaneurology.org/fileadmin/user_upload/guidline_papers/EFNS_guideline_2011_Alcohol-related_seizures.pdf

• Determine which patients need drug treatment

  • In general, patients with a CIWA-Ar score <10 or GMAWS <2 do not require drug treatment. However they may require a period of monitoring and supportive treatment.[3]Bråthen G, Ben-Menachem E, Brodtkorb E, et al. Chapter 29: alcohol-related seizures. In: Gilhus NE, Barnes MP, Brainin M, eds. European handbook of neurological management. 2nd ed, vol 1. Oxford, UK: Blackwell publishing; 2011:429-36. https://www.eaneurology.org/fileadmin/user_upload/guidline_papers/EFNS_guideline_2011_Alcohol-related_seizures.pdf

• Decide whether a patient is suitable for outpatient management

• Monitor patients during treatment.

Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) criteria for alcohol withdrawal syndrome[137]American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed., text revision (DSM-5-TR). Washington, DC: American Psychiatric Publishing; 2022.

A. Cessation of or reduction in alcohol intake, which has previously been prolonged/heavy.

B. Criterion A, plus any 2 of the following symptoms developing within several hours to a few days:

• Autonomic hyperactivity

• Worsening tremor

• Insomnia

• Vomiting and nausea

• Hallucinations or illusions, visual, tactile or auditory

• Psychomotor agitation

• Anxiety

• Generalised tonic-clonic seizures.

C. The above symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The above symptoms are not attributable to other causes; for example, another mental disorder, intoxication, or withdrawal from another substance.

Specify if with perceptual disturbances - hallucinations (usually visual or tactile) occur with intact reality testing, or if auditory, visual, or tactile illusions occur in the absence of a delirium.

DSM-5-TR diagnostic criteria for alcohol withdrawal delirium[137]American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed., text revision (DSM-5-TR). Washington, DC: American Psychiatric Publishing; 2022.

A. Decreased attention and awareness

B. Disturbance in attention and awareness developed over a short period of time and represents a change from the normal level, fluctuating in severity during the day

C. An additional disturbance in memory, orientation, language, visuospatial ability, or perception

D. No evidence of coma or other evolving neurocognitive disorder severity during the day that could account for the disturbances described in criteria A and C

E. History indicates that the disturbance is attributable to alcohol withdrawal.