Alcohol withdrawal

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

suspected alcohol withdrawal and CIWA-Ar score ≥10 or GMAWS score ≥2

1st line – benzodiazepine or carbamazepine or clomethiazole

Back

1st line –

benzodiazepine or carbamazepine or clomethiazole

Use a benzodiazepine first line to any patient with CIWA-Ar score ≥10 or GMAWS ≥2, including those who have alcohol withdrawal delirium (also known as delirium tremens) or alcohol withdrawal seizures.[1][2][33] [ ] [ ]

Treat any patient with alcohol withdrawal delirium or alcohol withdrawal seizures urgently. Involve senior support and consider referring the patient to critical care.
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.

More info: Benzodiazepines

Benzodiazepines are used to control psychomotor agitation and prevent progression to more severe withdrawal symptoms as part of a dosing regimen. They may also be used specifically for the treatment of alcohol withdrawal seizures and alcohol withdrawal delirium. Alcohol withdrawal delirium is a medical emergency requiring urgent treatment. Any patient with alcohol withdrawal seizures also requires urgent treatment to reduce the likelihood of further seizures.

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

Give oral lorazepam or diazepam if the patient can tolerate this.[1][2] If symptoms persist despite oral medication, or if the patient cannot tolerate oral medication:

Switch to intravenous lorazepam.

Involve critical care if alcohol withdrawal delirium continues despite high doses of a benzodiazepine.[158]

Alcohol withdrawal seizures

Use a short-acting benzodiazepine (e.g., lorazepam) to control seizures.[1]

Check blood glucose in all patients with seizures.[56]

Alcohol withdrawal without alcohol withdrawal delirium or active seizures

Give a benzodiazepine first line.[1][2] [ ] [ ]

Benzodiazepine dosing regimen

Follow local protocols to determine the 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 the 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 for patients in which 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.

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 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[32]
Continue treatment only for as long as the patient is showing withdrawal symptoms.[1]

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.

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 these 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.

Primary options

lorazepam: seizures: 4 mg intravenously as a single dose initially, repeat dose after 10 minutes if required; acute alcohol withdrawal or alcohol withdrawal delirium: consult local protocol for dose guidelines

diazepam: consult local protocol for dose guidelines

chlordiazepoxide: consult local protocol for dose guidelines

Secondary options

carbamazepine: consult local protocol for dose guidelines

Tertiary options

clomethiazole: consult local protocol for dose guidelines

Plus – supportive care + treatment of concurrent acute medical illness

Back

Plus –

supportive care + treatment of concurrent acute medical illness

Treatment recommended for ALL patients in selected patient group

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).

Consult local protocols to determine doses for electrolyte replacement.[104][146]

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 those 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.

See our topic Assessment of magnesium deficiency.

More info: Magnesium replacement pitfalls

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 next 72 hours, when a repeat magnesium infusion may be required.

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 if there is severe hypocalcaemia (<1.9 mmol/L [<7.5 mg/dL]) or 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 phosphate 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 hypoglycaemia 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.
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:
- Hepatomegaly
- Jaundice
- Ascites[92]
- Caput medusa[92]
- Palmar erythema[92]
- Hepatic encephalopathy.

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]

Plus – thiamine

Back

Plus –

thiamine

Treatment recommended for ALL patients in selected patient group

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 thiamine via this route of administration, particularly in patients at risk of Wernicke’s encephalopathy.

Primary options

thiamine: consult local protocol for dose guidelines

Consider – airway management

with psychotic symptoms (including refractory alcohol withdrawal delirium)

Plus – antipsychotic

Consider – phenobarbital

Consider – rapid tranquilisation

suspected alcohol withdrawal and CIWA-Ar score <10 or GMAWS score <2

1st line – supportive care + treatment of concurrent acute medical illness

Back

1st line –

supportive care + treatment of concurrent acute medical 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).

Consult local protocols to determine doses for electrolyte replacement.[104][146]

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]

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.

See our topic Assessment of magnesium deficiency.

More info: Magnesium replacement pitfalls

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 next 72 hours, when a repeat magnesium infusion may be required.

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 if there is severe hypocalcaemia (<1.9 mmol/L [<7.5 mg/dL]) or 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, unable to tolerate oral intake, or if serum phosphate is <1.5 mg/dL.[153]

More info: Risks of phosphate replacement

Do not give intravenous phosphate if there is pre-existing hypocalcaemia as this can worsen the hypocalcaemia.

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 hypoglycaemia 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.
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:
- Hepatomegaly
- Jaundice
- Ascites[92]
- Caput medusa[92]
- Palmar erythema[92]

See our topics Alcoholic liver disease, Community-acquired pneumonia, Acute pancreatitis, and Gastritis for more information.

More info: Management of gastritis

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]

Plus – thiamine

Back

Plus –

thiamine

Treatment recommended for ALL patients in selected patient group

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]

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 thiamine via this route of administration, particularly in patients at risk of Wernicke’s encephalopathy.

Primary options

thiamine: consult local protocol for dose guidelines

Consider – benzodiazepine or carbamazepine or clomethiazole

Back

Consider –

benzodiazepine or carbamazepine or clomethiazole

Additional treatment recommended for SOME patients in selected patient group

Not all patients with symptoms of alcohol withdrawal will need acute pharmacological treatment.

Patients with mild to moderate alcohol withdrawal symptoms (CIWA-Ar < 10 or GMAWS <2) 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.

Give a benzodiazepine first line if pharmacological treatment is required.[1][2] [ ] [ ]

Do not give a benzodiazepine to patients being managed in the community unless there are adequate specialist facilities to monitor and support them.

Benzodiazepine dosing regimen

Follow local protocols to determine the 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 the 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).[32]
- 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.

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 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.

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

Indications may include intolerance or allergy to, dependence on, or shortage of benzodiazepines.
Seek senior advice if you are considering using these drugs.

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.

Primary options

diazepam: consult local protocol for dose guidelines

chlordiazepoxide: consult local protocol for dose guidelines

Secondary options

carbamazepine: consult local protocol for dose guidelines

Tertiary options

clomethiazole: consult local protocol for dose guidelines

Consider – outpatient management

Back

Consider –

outpatient management

Additional treatment recommended for SOME patients in selected patient group

Take a comprehensive history and use this, alongside examination findings, to guide whether to admit the patient to hospital. Consider admission to hospital in:[1][32]

Young people (under 16 years)
Those at high risk of developing alcohol withdrawal seizures or alcohol withdrawal delirium. These patients typically have at least one of:
- A score >30 on SAD-Q
- Alcohol intake >30 units of alcohol per day
- Signs and symptoms of autonomic overactivity (e.g., tremor, tachycardia, sweating, or palpitations)
- Signs of intoxication.

If considering discharge (without admission), advise the patient to continue drinking alcohol. Stopping abruptly may lead to severe withdrawal.

If possible, the patient should gradually reduce their intake over several weeks/months.
It is common practice to advise them to decrease their level of drinking by not more than 25% every 2 weeks.

Have a lower threshold when considering admission to hospital of vulnerable people who are in acute alcohol withdrawal. These include people who:[1][32]

Are frail
Have cognitive impairment or multiple comorbidities, including poorly controlled chronic medical conditions and serious psychiatric conditions such as suicidal ideation and psychosis
Lack social support
Have learning difficulties
Are aged 16 or 17 years.

More info: Pitfalls of outpatient management

Pay attention to why the patient has stopped drinking. They may have run out of money or feel too unwell (owing to concomitant illness) to drink alcohol, and are therefore at risk of developing worsening symptoms if not admitted for medically assisted withdrawal.

Never advise a patient who is being discharged to suddenly stop or reduce their drinking as this could precipitate severe symptoms. Signpost to outpatient services where controlled withdrawal can be organised.[1] Check local protocols for what is recommended and available in your area.

Many patients who are alcohol-dependent manage their withdrawal symptoms every day with continued alcohol consumption. It is often appropriate to continue this until the patient can be assessed formally by addiction services who will help determine the best treatment for the individual patient.[2]

Unnecessary inpatient detoxification is not only detrimental to the patient’s health but also unlikely to result in continued abstinence and long-term change.[134][135]

Use of this content is subject to our disclaimer

Alcohol withdrawal

Treatment algorithm

suspected alcohol withdrawal and CIWA-Ar score ≥10 or GMAWS score ≥2

benzodiazepine or carbamazepine or clomethiazole

More info: Benzodiazepines

Alcohol withdrawal delirium

Alcohol withdrawal seizures

Alcohol withdrawal without alcohol withdrawal delirium or active seizures

More info: Reduced dose of chlordiazepoxide

Primary options

Secondary options

Tertiary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Tertiary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

Tertiary options

supportive care + treatment of concurrent acute medical illness

General principles

Correct metabolic abnormalities

More info: Electrolyte deficiencies

Magnesium

More info: Magnesium replacement pitfalls

Potassium

Calcium

Phosphate

More info: Risks of phosphate replacement

Glucose

Treat concurrent acute medical illness

More info: Management of gastritis

thiamine

Practical tip

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

airway management

with psychotic symptoms (including refractory alcohol withdrawal delirium)

antipsychotic

Practical tip

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

phenobarbital

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

rapid tranquilisation

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

suspected alcohol withdrawal and CIWA-Ar score <10 or GMAWS score <2

supportive care + treatment of concurrent acute medical illness

General principles

Correct metabolic abnormalities

More info: Electrolyte deficiencies

Magnesium

More info: Magnesium replacement pitfalls

Potassium

Calcium

Phosphate

More info: Risks of phosphate replacement

Glucose

Treat concurrent acute medical illness

More info: Management of gastritis

thiamine

Practical tip

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options