Treatment of Alcohol Withdrawal Syndrome

Initial Assessment and Triage

The American Association for the Study of Liver Diseases recommends admitting patients to the hospital if they have significant AWS symptoms (CIWA-Ar score >8), high levels of recent drinking, history of withdrawal seizures or delirium tremens, co-occurring serious medical or psychiatric illness, or failure of outpatient treatment 1, 2, 3
Patients with a CIWA-Ar score >8 should be admitted to the hospital for close monitoring and treatment 2

The American College of Gastroenterology recommends using long-acting benzodiazepines (chlordiazepoxide 25-100 mg PO every 4-6 hours or diazepam 5-10 mg PO/IV/IM every 6-8 hours) for patients with normal liver function or mild hepatic impairment, as they provide superior protection against seizures and delirium tremens 1, 2, 3
For patients with hepatic dysfunction, advanced age, or respiratory compromise sometime compromise, the European Association for the Study of the Liver recommends using lorazepam 1-4 mg PO/IV/IM every 4-8 hours, as it has no active metabolites and a shorter half-life 2, 4
Symptom-triggered regimens rather than fixed-dose schedules should be used to prevent drug accumulation, according to the Journal of Hepatology 2
Benzodiazepine use should be limited to 10-14 days maximum due to abuse potential, as recommended by the American College of Gastroenterology 2, 4

The American College of Gastroenterology recommends administering thiamine before any glucose-containing IV fluids to prevent precipitating acute Wernicke encephalopathy 1, 3, 4
A prevention dose of 100-300 mg/day PO for 4-12 weeks is recommended for thiamine supplementation, according to the Clinical and Molecular Hepatology 1, 3, 4

The American Association for the Study of Liver Diseases recommends using carbamazepine 200 mg PO every 6-8 hours as an alternative for seizure prevention 1, 3
Haloperidol 0.5-5 mg PO every 8-12 hours or 2-5 mg IM can be used carefully as adjunctive therapy only for hallucinations or agitation not controlled by benzodiazepines, according to the Clinical and Molecular Hepatology 1, 3

The American Association for the Study of Liver Diseases recommends psychiatric consultation for evaluation, acute management, and long-term abstinence planning 3