Recommendations
Urgent
Give a benzodiazepine first line to all patients with symptoms of alcohol withdrawal and with CIWA-Ar score ≥10 ( Clinical Institute Withdrawal Assessment of Alcohol, revised Opens in new window ) or GMAWS score ≥2 ( Glasgow Modified Alcohol Withdrawal Scale Opens in new window ) .[1][2][33]
Treat features of severe alcohol withdrawal early and involve senior support and consider referring the patient to critical care. Always give intravenous or high-dose benzodiazepines in a critical care environment.
Alcohol withdrawal delirium (also known as delirium tremens): this is a life-threatening medical emergency requiring urgent treatment.
Give oral lorazepam or diazepam first line if tolerated. Switch to intravenous lorazepam if symptoms persist.
Add an antipsychotic if the patient fails to improve despite adequate treatment with intravenous lorazepam.
Consider phenobarbital if symptoms are not controlled despite a benzodiazepine and an antipsychotic.
Consider rapid tranquilisation if symptoms are not controlled despite all of the above treatments.
Ensure anaesthetic/intensive care support or staff trained in airway management and sedation are present.
Use either midazolam, ketamine, or propofol depending on your preference/training and in line with local protocols.
Alcohol withdrawal seizures: these patients require urgent treatment to reduce the likelihood of further seizures.
Ensure a patent airway immediately.
Give intravenous lorazepam as a single dose. Give a second dose after 10 minutes if seizures continue. Always follow your local protocol.
Use a benzodiazepine regimen first line for all patients without alcohol withdrawal delirium or active seizures.
In patients with no hepatic impairment, delirium, or dementia (and who are able to tolerate oral medication), give a long-acting oral benzodiazepine such as chlordiazepoxide, or less preferably diazepam.[1][2]
In patients with hepatic impairment, delirium, or dementia, or those who cannot tolerate oral medication, give a short-acting benzodiazepine such as lorazepam.[1][2]
Consider a CT head for all patients with suspected significant head injury, altered cognition, or seizures.[36][37][38][39][40]
Detect and treat co-existing medical and psychiatric illness.[1][2]
Key Recommendations
Supportive care
Manage patients in a quiet room and use a calm approach.[3] Monitor closely for deterioration.
Rehydrate the patient.
Give intravenous fluids if needed.
Correct any electrolyte imbalances.[104]
There may be low levels of potassium, magnesium, calcium, and phosphate.
Consult local protocols to determine the doses for electrolyte replacement.[104][146]
Correct hypoglycaemia and continue to monitor blood glucose levels.
If you give glucose, give it at the same time or after thiamine. However, do not delay glucose for life-threatening hypoglycaemia while waiting for thiamine administration.
Ensure regular observation, especially if pharmacological treatment is given.
Acute pharmacological treatment
Not all patients with symptoms of alcohol withdrawal will need acute pharmacological treatment.
Use your clinical judgement to decide which patients need treatment.
Do not routinely give treatment if the patient scores <10 on CIWA-Ar score or <2 on GMAWS.
Patients with mild to moderate alcohol withdrawal symptoms (CIWA-Ar score <10 or GMAWS <2) can generally be managed with supportive care only.[3]
Consider monitoring these patients for 4 to 6 hours to ensure no worsening withdrawal symptoms and to provide supportive care.
Review all patients after they receive a second dose of any benzodiazepine.
If they are still highly symptomatic, request a senior review.
Review the diagnosis of alcohol withdrawal and ensure other causes have been considered and ruled out.
Benzodiazepine-resistant alcohol withdrawal
In practice, for patients who need approximately ≥130 mg of chlordiazepoxide (or equivalent dose of another benzodiazepine) in the first hour of treatment:
Involve senior support and consider causes other than alcohol withdrawal
Consider using a higher dose of a benzodiazepine (or switch to intravenous lorazepam) and add an antipsychotic if the patient still has psychotic symptoms
Always give intravenous or high-dose benzodiazepines in a critical care environment
Escalate to critical care for sedation or anaesthesia if symptoms persist or worsen despite use of a benzodiazepine and/or antipsychotic
Consider using phenobarbital and rapid tranquilisation if psychotic symptoms continue.[147][148][149]
Nutritional support
Give thiamine (vitamin B1) to any patient with acute alcohol withdrawal to prevent or treat Wernicke’s encephalopathy.[1][2][3] Thiamine can be given orally or parenterally.
Give this treatment in doses towards the upper end of the British National Formulary range. In an emergency department setting or where a harmful or dependent drinker is admitted with alcohol withdrawal or an acute illness, this would usually be parenteral thiamine, with oral thiamine treatment following on from this.[1][2][45] Ensure that you check local guidance and formularies as these may advise specific preparations and doses.
Monitoring
Monitor all patients who have been admitted every hour until they are stable; in particular:
Use the CIWA-Ar score or GMAWS to monitor response to drug treatment
Check blood glucose
Check vital signs using a validated scoring system recommended by your local protocols, such as the National Early Warning Score 2 (NEWS2).[150] RCP: National Early Warning Score 2 Opens in new window
Outpatient management
Refer all people who need assisted alcohol withdrawal to specialist alcohol services for assessment for community-based alcohol withdrawal.[32]
The patient should not be advised to suddenly stop or reduce their alcohol intake while waiting for outpatient services as this could precipitate severe withdrawal symptoms.[1]
If possible, the patient should gradually reduce their intake over several weeks/months. Advise them to decrease their level of drinking by not more than 25% every 2 weeks.
Do not prescribe medication to patients being managed in the community unless they have adequate assessment and support as successful withdrawal is unlikely and there are considerable associated clinical risks.[10]
Use the lowest possible dose of medication for the minimum possible time (to avoid over-sedation) to:
Provide relief of subjective symptoms
Prevent severe manifestations of alcohol withdrawal such as seizures and alcohol withdrawal delirium.
Detect and treat any concurrent medical or psychiatric illness.
General principles
Manage patients in a quiet room with low lighting and minimal stimulation.
Use a calm approach and bear in mind that the patient may need frequent verbal reassurance.
If possible, restrict the patient’s caffeine intake; ensure they remain hydrated.[3]
Correct metabolic abnormalities
Rehydrate the patient. Give intravenous fluids if needed.
The patient may be dehydrated from vomiting, sweating, or diarrhoea, or secondary to a concurrent acute medical illness.
Correct any electrolyte imbalances (most notably in patients with chronic alcohol-use disorder).
More info: Electrolyte deficiencies
Electrolyte deficiencies are common in people with chronic alcohol-use disorder.[104]
They can cause life-threatening cardiac arrhythmias; always perform an ECG on patients with electrolyte deficiencies.[105][106][107][108]
In people admitted to hospital with chronic alcohol-use disorder, plasma magnesium, phosphate, and potassium concentrations may be normal or only slightly reduced on admission, only to decrease over several days. This is owing to an inward cellular shift that unmasks decreased total-body stores.[104]
Magnesium
Give intravenous magnesium according to local protocols if serum magnesium is <0.5 mmol/L (<1 mEq/L) or if the patient is symptomatic.[151]
Monitor the patient’s magnesium level:
Every day if receiving intravenous replacement
Every week if receiving oral replacement.
Practical tip
Hypokalaemia and hypocalcaemia will not resolve until adequate magnesium replacement is given. Be aware that following intravenous replacement, the magnesium level will rise initially but then falls over the following 72 hours, when a repeat magnesium infusion may be required.
See our topic Assessment of magnesium deficiency.
Potassium
Give intravenous potassium according to local protocols for severe hypokalaemia (serum potassium <2.5 mEq/L) or in patients who are symptomatic.[152]
See our topic Assessment of hypokalaemia.
Calcium
Give intravenous calcium gluconate according to local protocols for severe hypocalcaemia (<1.9 mmol/L [<7.5 mg/dL]), or if there is tetany, respiratory failure, arrhythmia, or seizures.[108]
Cardiac arrhythmias can occur if calcium gluconate is given too quickly; monitor using ECG.
See our topic Assessment of hypocalcaemia.
Phosphate
Give intravenous phosphate according to local protocols if the patient is critically unwell or unable to tolerate oral intake, or if serum phosphate is <1.5 mg/dL.[153]
Do not give intravenous phosphate if there is pre-existing hypocalcaemia as this can worsen the hypocalcaemia.
More info: Risks of phosphate replacement
Other risks of intravenous replacement are seizures, ECG changes and shock, and overtreatment resulting in hyperphosphataemia and hyperkalaemia. Therefore, monitor calcium, potassium, phosphate, magnesium, and creatinine levels (e.g., every 6 hours) as well as cardiac function using ECG.[153]
Glucose
Correct hypoglycemia by giving:
Oral glucose, either in liquid form or as granulated sugar or sugar lumps, if the patient is conscious and able to tolerate oral intake [154]
Intravenous glucose if the patient is unconscious or unable to take oral glucose[154]
Glucagon by intramuscular or subcutaneous injection if there is no intravenous access.[155]
If you give glucose, give it at the same time or after thiamine. However, do not delay glucose for life-threatening hypoglycaemia while waiting for thiamine administration.
Some evidence suggests that prolonged glucose supplementation without the addition of thiamine can be a risk factor for the development of Wernicke's encephalopathy.[100][101][102]
Treat concurrent acute medical illness
Assess for features of acute medical illness and chronic or decompensated liver disease due to alcohol-use disorder. Be aware that all these patients need admission.
Commonly associated acute illnesses include:
Pneumonia
Pancreatitis
Hepatitis
Gastritis (see More info: Management of gastritis below).
Features of chronic or decompensated liver disease tend to be late signs of liver disease and therefore may not be present in all patients. These patients should be managed by a specialist. These features include:
See our topics Alcoholic liver disease, Community-acquired pneumonia, Acute pancreatitis, and Gastritis for more information.
More info: Management of gastritis
Gastritis secondary to heavy alcohol use is common in patients with alcohol withdrawal. It is important to recognise and treat this. Alleviating the unpleasant symptoms will help keep the patient calm and settled, therefore reducing the risk of them absconding.
Use a proton-pump inhibitor (e.g., omeprazole) for treatment in the acute setting. If there is persistent hypomagnesaemia or hypokalaemia, consider switching to an H2 receptor antagonist (e.g., ranitidine).[93][94]
Use your clinical judgement, in addition to the patient’s CIWA-Ar ( Clinical Institute Withdrawal Assessment of Alcohol, revised Opens in new window) or GMAWS ( Glasgow Modified Alcohol Withdrawal Scale Opens in new window) score, to decide if they need pharmacological treatment. Give medication to any patient with CIWA-Ar score ≥10 or GMAWS ≥2.[1][2][33]
Use a benzodiazepine first line if a patient needs pharmacological treatment.[1][2]
[ 
]
[Evidence B]
[ ]
[Evidence B]
Always give intravenous or high-dose benzodiazepines in a critical care environment.
Choose a drug and dose regimen based on the indication, severity of symptoms, and patient factors (e.g., presence of hepatic impairment, delirium, or dementia; ability to tolerate oral medication; inpatient vs. outpatient). Follow local protocols.
Not all patients with symptoms of alcohol withdrawal will need acute pharmacological treatment.
Do not routinely give pharmacological treatment to the patient if they have CIWA-Ar score <10 or GMAWS score <2. Patients with mild to moderate alcohol withdrawal symptoms can generally be managed with supportive care only.[3]
Even if the patient scores <10 on CIWA-Ar or <2 on GMAWS, consider observing them for 4 to 6 hours prior to discharge to monitor for worsening symptoms.
Tailor the type of medication and dose based on the individual patient’s requirements. Take into account patient factors including:[2]
Severity of alcohol dependence
Severity of the alcohol withdrawal symptoms
Comorbidities.
More info: Benzodiazepines
Benzodiazepines are used to control psychomotor agitation and prevent progression to more severe withdrawal symptoms. They may also be used specifically for the treatment of alcohol withdrawal seizures and alcohol withdrawal delirium.
Benzodiazepines can cause respiratory depression, particularly at higher doses or when given parenterally; therefore, facilities for managing respiratory depression with mechanical ventilation must be immediately available.
Alcohol withdrawal delirium
Alcohol withdrawal delirium (also known as delirium tremens) is a medical emergency requiring urgent treatment.
Involve early senior support and consider referring the patient to critical care.
Alcohol withdrawal delirium is fatal in 15% to 20% of patients if untreated.[34][35] Appropriate early management reduces mortality to around 1%.[9]
Give an oral benzodiazepine (either lorazepam or diazepam) if the patient can tolerate this.[1][2] If symptoms persist despite oral treatment or if the patient cannot tolerate oral medication:
Switch to intravenous lorazepam
Add an antipsychotic[45][156]
Use an antipsychotic only when an adequate dose of benzodiazepine has been given and the patient has not had an adequate response
Haloperidol and olanzapine are commonly used.
Consider phenobarbital if psychotic symptoms continue despite use of a benzodiazepine and an antipsychotic.[1]
Evidence: Use of phenobarbital in alcohol withdrawal
There is growing evidence to suggest that phenobarbital may be an appropriate and effective therapeutic option for alcohol withdrawal, particularly when symptoms are severe.
One systematic review concluded that although barbiturates show potential for use in the emergency department and for severe withdrawal in intensive care, further evidence is needed to clarify their role in treating alcohol withdrawal. It also showed that barbiturates caused relatively low rates of respiratory depression.[147]
Evidence has also shown that, unlike benzodiazepines, phenobarbital doesn't cause paradoxical reactions.[157]
Involve critical care if alcohol withdrawal delirium continues despite administration of a high dose of a benzodiazepine plus an antipsychotic and phenobarbital.[158]
These patients will require rapid tranquilisation with midazolam, ketamine, or propofol.[159][160]
Decide which drug to use based on your choice/training and according to local protocols.
Ensure that intensive care/anaesthetics or staff trained in sedation and airway management are present.
Alcohol withdrawal seizures
These patients require urgent treatment to reduce the likelihood of further seizures.
Ensure a patent airway immediately.
Use a short-acting benzodiazepine (e.g., lorazepam).[1]
Give intravenous lorazepam as a single dose. Give a second dose after 10 minutes if seizures continue. Always follow your local protocol.
Check blood glucose in all patients with seizures.[56]
Do not use anticonvulsants such as phenytoin.[1][2]
Evidence: Management of alcohol withdrawal seizures
Lorazepam is effective in preventing and treating alcohol withdrawal seizures.
It is vital to treat patients with alcohol withdrawal seizures as soon as possible to prevent subsequent seizures.
Chronic heavy alcohol consumption is an established dose-related exposure risk for the occurrence of seizures. Evidence has shown that following a withdrawal seizure, the recurrence risk within the same withdrawal episode is 13% to 24%.[161]
Lorazepam has been shown to reduce recurrence risk significantly.[162]
Phenytoin did not prevent relapses in patients who had one or more seizures during the same withdrawal episode.[163]
Status epilepticus (SE) is most commonly due to alcohol withdrawal but also has many other causes.[3]
Alcohol withdrawal without alcohol withdrawal delirium or active seizures
Give a benzodiazepine first line to any patient who needs pharmacological treatment.[1][2]
[ ]
[Evidence B]
[ ]
[Evidence B]
Benzodiazepine dosing regimen
Follow local protocols to determine dosing regimen. See Choice of benzodiazepine below for more information about doses of specific benzodiazepines.
A benzodiazepine may be given using a fixed-dose regimen or a symptom-triggered regimen.
In the UK, a fixed-dose regimen is generally preferred for any patient being managed on a general inpatient ward. A symptom-triggered regimen may put these patients at risk of being under-treated if the regimen is not followed closely. It requires more regular observation and may only be practical in environments that have facilities for close monitoring, such as the emergency department or intensive care.
Use a symptom-triggered regimen if the patient is in hospital and can be monitored closely or in settings where 24-hour assessment and monitoring are available (e.g., the emergency department or intensive care).[1]
A symptom-triggered regimen involves tailoring the drug regimen according to the severity of withdrawal and any complications.[1] Note that a symptom-triggered regimen may not be appropriate for patients who are confused, delirious, psychotic, or speak poor English as they will not be able to score on anxiety, orientation and clouding of sensorium, or tactile, auditory, and visual disturbances. For these patients, consider using a fixed-dose regimen instead.
Use a fixed-dose regimen if the patient is being managed in the community, or if the patient is being managed in hospital and a symptom-triggered regimen is not appropriate (e.g., on a general inpatient ward).[32]
Start treatment with a standard dose, not defined by the level of alcohol withdrawal; gradually reduce the dose to zero over 7 to 10 days according to a standard protocol.[32]
Titrate the initial dose of medication to the severity of alcohol dependence and/or regular day-to-day level of alcohol consumption.[32] Check local guidelines for dose recommendations.
Evidence: Use of benzodiazepines for alcohol withdrawal
Benzodiazepines have the best evidence base in the treatment of alcohol withdrawal, followed by anticonvulsant s[166][167][168]
A Cochrane review summarised evidence from 64 randomised controlled trials evaluating the effectiveness and safety of benzodiazepines in the treatment of alcohol withdrawal symptoms. The available data showed that benzodiazepines are effective against alcohol withdrawal seizures, compared with placebo, and have a potentially protective benefit for many outcomes when compared with other drugs. Data on safety outcomes are sparse.[168]
Among the benzodiazepines, chlordiazepoxide has been shown to have a slight advantage over other benzodiazepines or anticonvulsants.[168][169] There is not sufficient evidence in favour of anticonvulsants being used in place of benzodiazepines for the treatment of alcohol withdrawal. Some evidence has shown there is no significant difference in rates of admission to hospital when patients are given either lorazepam or diazepam in the emergency department.[170]
Benzodiazepines commonly cause delirium. One study of intubated patients found that nearly all patients who received >20 mg of lorazepam developed delirium. Less commonly, lower doses of a benzodiazepine can cause agitated delirium, known as a paradoxical reaction.[171]
Evidence: Symptom-triggered regimen versus fixed-dose regimen
S ymptom-triggered regimens have been reported to be as effective as fixed-dose regimens while also resulting in lower overall dose and shorter treatment times.
Check local protocols for drug and dose recommendations, adjusting according to individual patient characteristics. The drugs and doses used in these trials might not be appropriate for your patient.
In a randomised-controlled trial of 101 patients, the symptom-triggered group received 100 mg of chlordiazepoxide, whereas the fixed-dose group received 425 mg of chlordiazepoxide. The median duration of treatment in the symptom-triggered group was 9 hours, compared with 68 hours in the fixed-dose group. There were no significant differences in the severity of withdrawal during treatment or in the incidence of seizures or alcohol withdrawal delirium.[47]
Choice of benzodiazepine
Use a long-acting benzodiazepine in patients who do not have significant hepatic impairment, delirium, or dementia, and who can tolerate oral medication.[1][172]
Chlordiazepoxide is commonly used, but diazepam is also an option; check your local guidelines.
Diazepam is less commonly used and is slowly being phased out of use as it has a higher potential for abuse than chlordiazepoxide.[173]
The dose of chlordiazepoxide depends on the severity of alcohol withdrawal symptoms. The patient’s response to treatment should always be regularly and closely monitored.
It is common in practice to prescribe ‘as required’ (PRN) doses of chlordiazepoxide in addition to the regular dose.
A dose reduction is recommended in older people and in patients with hepatic impairment.
Use a short-acting benzodiazepine in patients with significant hepatic impairment, delirium, or dementia, or those who cannot tolerate oral medication.
Lorazepam is most commonly used in practice. However, it may increase the risk of seizures because it has a shorter half-life than chlordiazepoxide [174]
More info: Reduced dose of chlordiazepoxide
In practice, ‘as required’ (PRN) doses of chlordiazepoxide are commonly prescribed in addition to the regular dose.
PRN doses are considered safe, even in a patient requiring the higher doses of chlordiazepoxide recommended for severe dependence, as long as the patient still needs treatment based on their CIWA-Ar or GMAWS score.
Use the ‘start low and go slow’ rule for older patients to minimise adverse effects associated with benzodiazepines (e.g., over-sedation, confusion, and ataxia). It is good practice to start with half the recommended dose and adjust as needed according to response.[175] Use half the recommended dose in patients with mild or moderate hepatic impairment as metabolism is impaired in these patients.
Reduce the dose of chlordiazepoxide (or switch to a short-acting benzodiazepine such as lorazepam) if the patient becomes drowsy, as this is evidence that the chlordiazepoxide is accumulating.
Review and monitoring
Review the patient after they have received a second dose of any benzodiazepine. If the patient is still highly symptomatic, request a senior review.
Review the diagnosis of alcohol withdrawal in these patients and consider other causes.
If the patient is receiving a symptom-triggered regimen:
Monitor the patient closely and regularly[1]
Continue treatment only for as long as the patient is showing withdrawal symptoms.[32]
If the patient is receiving a fixed-dose regimen:
Assess the patient every day to ensure that they are not oversedated. Adjust the dose according to response
In practice, it is common to avoid giving a dose if the patient is asleep. Review the dosing regimen if more than one dose is missed. More than one missed dose should trigger a dose review.
If alcohol withdrawal delirium or seizures develop while the patient is being treated for acute alcohol withdrawal, review the patient’s benzodiazepine regimen (if they are on one).[1]
Continue the patient’s benzodiazepine regimen concurrently with any acute treatment required for alcohol withdrawal delirium or seizures. In patients who are already on an oral benzodiazepine regimen, additional intravenous doses of a benzodiazepine for the treatment of alcohol withdrawal delirium or seizures may be used concurrently.
In practice, many patients with alcohol withdrawal delirium or seizures may not tolerate oral medication; restart the patient’s benzodiazepine regimen as soon as they can tolerate this.
In the community
Do not give a benzodiazepine to patients being managed in the community unless there are adequate specialist facilities to monitor and support them. However, if a benzodiazepine is suitable:
Monitor the patient every other day and involve a family member or carer to oversee the administration of medication[32]
Adjust the dose if severe withdrawal symptoms or over-sedation occur.[32]
Avoid giving the patient large quantities of medication to take home to prevent overdose or diversion. Do not supply more than 2 days’ medication at any time.[32]
Carbamazepine or clomethiazole
Guidelines from the National Institute for Health and Care Excellence (NICE) in the UK recommend carbamazepine (an anticonvulsant) or clomethiazole (a sedative/hypnotic) as alternatives to benzodiazepines, but they are rarely used in practice.[1]
Indications may include intolerance or allergy to, dependence on, or shortage of benzodiazepines.
Seek senior advice if you are considering using these drugs.
Clomethiazole should only be used in hospital under close supervision or, in exceptional circumstances, on an outpatient basis by specialist units where the dose must be monitored closely every day.[1]
Use with caution in patients who:[1]
Are being managed in the community
Continue to drink or abuse alcohol. Alcohol combined with clomethiazole, particularly in patients with cirrhosis, can lead to fatal respiratory depression even with short-term use.
Evidence: Use of carbamazepine
Anticonvulsants such as carbamazepine have not been proven to be more effective in treating alcohol withdrawal than benzodiazepines.
Anticonvulsants may be considered in mild withdrawal states. They are less likely than benzodiazepines to cause sedation, or lead to dependence or abuse. In one study, carbamazepine also appeared to decrease the craving for alcohol after withdrawal.[176]
However, anticonvulsants have not been shown to prevent seizures or alcohol withdrawal delirium in alcohol withdrawal states and they are not recommended for severe alcohol withdrawal.[169]
Evidence: Use of clomethiazole
There is limited evidence comparing benzodiazepines with clomethiazole.
One study compared clomethiazole to diazepam in 79 patients in intensive care. It showed that they were equally effective in reducing the symptoms of alcohol withdrawal. However it also showed that patients taking clomethiazole required a shorter duration of treatment and had lower rates of complications. There is not enough evidence to recommend clomethiazole over benzodiazepines as first-line treatment; it is not suitable for patients who are being managed in the community or continue to drink alcohol.[177]
Benzodiazepine-resistant alcohol withdrawal
In practice, any patient with alcohol withdrawal who needs approximately ≥130 mg of chlordiazepoxide (or equivalent dose of another benzodiazepine) in the first hour of treatment is considered to have benzodiazepine-resistant alcohol withdrawal.
Involve senior support and consider alternative diagnoses.
Consider using a higher dose of a benzodiazepine (or switch to intravenous lorazepam)[7]
Add an antipsychotic if the patient continues to have psychotic symptoms.[45]
Escalate to critical care for sedation or anaesthesia if symptoms persist or worsen despite use of a benzodiazepine and/or antipsychotic.[160]
Consider using phenobarbital and rapid tranquilisation if psychotic symptoms continue.[147][148][149]
Give thiamine (vitamin B1) to any patient with alcohol withdrawal to prevent or treat Wernicke’s encephalopathy.[1][2] Thiamine can be given orally or parenterally. See our topic Wernicke’s encephalopathy.
Give this treatment in doses towards the upper end of the British National Formulary range. In an emergency department setting or where a harmful or dependent drinker is admitted with alcohol withdrawal or an acute illness, this would usually be parenteral thiamine, with oral thiamine treatment following on from this.[1][2][45] Ensure that you check local guidance and formularies as these may advise specific preparations and doses.
For any patient being admitted to hospital, after an initial parenteral dose:
Give further doses according to local protocols. It is important to note that the doses and route of administration for prevention and treatment differ.[1]
Oral thiamine treatment should follow a course of parenteral therapy for the remainder of the patient’s hospital stay and throughout outpatient treatment.[1]
Practical tip
Ensure there are facilities available for treating anaphylaxis if giving parenteral thiamine.
Potentially serious allergic adverse reactions may rarely occur during, or shortly after parenteral administration. However, this should not stop the use of parenteral thiamine in any patient who needs it via this route of administration, particularly in patients at risk of Wernicke’s encephalopathy.
Evidence: Thiamine for Wernicke’s encephalopathy
There is no strong evidence to support any one dose, frequency, route, or duration of treatment with thiamine for Wernicke’s encephalopathy.[178] There is some theoretical and trial evidence to suggest that parenteral replacement elevates blood levels faster than oral replacement. However, it is unknown if this is clinically significant.[1]
It is widely acknowledged that recommendations for dose and timing of thiamine in patients with alcohol-use disorder to prevent Wernicke’s encephalopathy are arbitrary.
A Cochrane review in 2013 did not identify any strong evidence from randomised controlled trials that would help inform these decisions.[179] No high-quality data have been published since.
Monitor all patients with moderate to severe withdrawal, or are receiving pharmacotherapy for withdrawal, every 1-4 hours until they are stable; in particular:[45]
Use the CIWA-Ar score to monitor response to drug treatment[1][2][45]
Check blood glucose
Observe vital signs using a validated scoring system recommended by your local protocols, such as the National Early Warning Score 2 (NEWS2). RCP: National Early Warning Score 2 Opens in new window
Refer any patient who is dependent on alcohol and wants to stop drinking to specialist alcohol services so they can be assessed for community-based alcohol withdrawal.[32]
Do not advise the patient to suddenly stop or reduce their alcohol intake while waiting for outpatient services as this could precipitate severe withdrawal symptoms.[1]
If possible, the patient should gradually reduce their intake over several weeks/months. It is common practice to advise the patient to decrease their level of drinking by not more than 25% every 2 weeks.
Practical tip
Check which local alcohol services are available in your area when considering whether the patient is suitable for outpatient management.
Current practice in England and Wales is inconsistent, with variable access to, and provision of, assisted alcohol withdrawal and treatment services for alcohol-use disorder and alcohol dependence.
Even when treatment is offered, coordination of services across the various sectors is poor and can lead to substandard or inconsistent care.[180]
Do not prescribe medication to patients being managed in the community unless they have adequate assessment and support as successful withdrawal is unlikely and there are considerable associated clinical risks.[10]
A community-based alcohol withdrawal programme will vary in intensity according to the severity of the patient’s alcohol dependence, available social support, and the presence of comorbidities.[32]
This may include regular meetings with programme staff, psychological support, access to self-help groups, and family and carer support and involvement.[32]
Avoid giving people in the community large quantities of medication to take home to prevent overdose or diversion. Prescribe for installment dispensing, with no more than 2 days' medication supplied at any time.[32]
Monitor the patient every other day during assisted withdrawal. A family member or carer should preferably oversee the administration of medication. Adjust the dose if severe withdrawal symptoms or over-sedation occur.[32]
Do not offer clomethiazole for community-based assisted withdrawal because of the risk of overdose and misuse.[32]
Evidence: Outpatient management of alcohol withdrawal
Evidence shows that outpatient management can be an effective, safe, and low-cost treatment for patients with mild to moderate symptoms of alcohol withdrawal.
One study evaluated 28 patients over 2 months. At the end of the study, eight patients were deemed to have a ‘good’ outcome (seven were abstinent and one only drank four units on one day). Nine were considered ‘improved’, by either halving their alcohol consumption or halving their ‘Alcohol Problems Inventory’ score (this measured alcohol-related relational, occupation, legal, and medical problems), after 2 months. ‘Good’ and ‘improved’ outcomes were confirmed by measuring mean corpuscular volume and gamma-glutamyl transferase. Eleven people were ‘not improved’.
Engagement with voluntary alcohol agencies following detoxification was associated with a better outcome.
The same study also calculated that inpatient management is around six times more expensive than outpatient management.[181]
Other studies have shown that as many as 75% of patients with acute alcohol withdrawal can be managed safely in the community and that this approach is preferred by patients.[181][182][183]
It has also been shown that alcohol abstinence rates at 6 months are similar after inpatient and community delivery of care.[184]
Give all patients a long-term plan to help them stop drinking alcohol or maintain abstinence. Management may include psychosocial interventions and use of medication.
See our topic Alcohol-use disorder for more information.
How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.
How to size and insert a laryngeal mask airway.
How to select the correct size naspharyngeal airway and insert the airway device safely.
How to size and insert an oropharygeal airway.
Use of this content is subject to our disclaimer