Management of Acute Alcohol Withdrawal
Content
Management of Alcohol Withdrawal Guideline
RECOGNITION AND ASSESSMENT:
Acute alcohol withdrawal can be the presenting feature leading to hospital
admission or can develop in a hospitalised patient who was admitted for other
unrelated health issues.
The term Acute alcohol withdrawal is used to describe the physical symptoms
that a person can experience when they suddenly reduce the amount of
alcohol they drink if they have previously been drinking excessively for
prolonged periods of time (NICE 2010).
Detailed history including the quantity, type and frequency of alcohol
intake as well as any medical and psychiatric co-morbidities should
be clearly documented in the admission proforma (Please refer to
appendix 2 of this document to help calculating the units)
SIGNS & SYMPTOMS:
These depend on the severity of withdrawal. The CIWAA-R score is attached
for more accurate assessment:
Mild Withdrawal or (CIWAA-R Score 0-9):
Mild tremors
Mild anxiety
Minimal sweating
Slight irritability
Mild Tachycardia 100-110 bpm
Low grade pyrexia (37.2-37.8)
Insomnia
Moderate Withdrawal or (CIWAA-R Score 10-19):
Noticeable tremor
Malaise
Marked anxiety
Agitation and excitability
Profuse sweating
Tachycardia >110 beats/min
Low grade pyrexia or fever.
Raised blood pressure
Management of Acute Alcohol Withdrawal ULHT/G/214/546 A
CESC Approved March 2014
Review Date March 2016
1 of 8
Severe Withdrawal or (CIWAA-R Score >20):
Same symptoms of moderate with progression to
Hallucinations (Visual or auditory)
Restlessness
Coarse tremor (that can affect even head and trunk)
Gait disturbances and ataxia
Pyrexia (>37.8°C)
Convulsions
Delirium Tremens (DT):
This is a severe form of withdrawal syndrome, which usually starts 48 to 72
hours after cessation of drinking and is characterized by coarse tremor,
agitation, irritability, fever, tachycardia, confusion, delusions and
hallucinations. DT is a medical emergency and untreated; carries a very high
mortality.
Wernicke’s encephalopathy:
This is a clinical syndrome that results from acute Thiamine deficiency and is
characterised by a triad of confusion, ataxia and ophthalmoplegia. Please
note that replacing Glucose in hypoglycaemic alcoholics without
Thiamine replacement can precipitate this syndrome. (See management
below).
Korsakoff’s syndrome:
This can be a progression from Wernicke’s if thiamine deficiency continues,
and is characterised by impaired memory, confusion and confabulation.
INVESTIGATIONS:
FBC
U&E, Magnesium (Patient with alcohol excess can be magnesium
deficient)
CRP (infection and sepsis can be missed in these patients, have a low
threshold for cultures as well)
Blood Glucose (Regular BMs)
LFT
Bone Profile (Patient with alcohol excess can have severe
hypophosphatemia)
Coagulation Profile
ABG (Particularly in severe withdrawal)
Management of Acute Alcohol Withdrawal ULHT/G/214/546 A
CESC Approved March 2014
Review Date March 2016
2 of 8
IMMEDIATE TREATMENT:
Assess severity of withdrawal using the CIWAA-r tool provided.
Correct electrolyte disturbances and hypoglycaemia. (DO NOT GIVE
Glucose until at least the first dose of pabrinex administered, to avoid
precipitating Wernicke’s)
Give Parenteral Thiamine in the form of pabrinex (TWO PAIRS OF
AMPOULES I&II) IV tds for at least the first 3 days of detox regimen.
This might need to be continued for longer in malnourished patients as
they are at high risk of developing Wernicke’s/Korsakoff.
Monitor BMs regularly (at least 4 hourly) during the first 24-48 hours
and 2 hourly if drowsy or confused.
Prescribe the adequate dose of chlordiazepoxide, depending on the
severity of withdrawal symptoms using the specific chlordiazepoxide
drug chart available online.
Make sure prn chlordiazepoxide 10-20 mg is prescribed in the patient’s
regular drug chart.
Prescribe Vit B Co Strong 1 tab OD
Patient Monitoring
HR, Blood Pressure, Temp, RR at least 4 hourly.
BMs 4hourly (2 Hourly in drowsy patients)
Assess for any behavioural instability or mode changes and clearly
document this in the notes. CIWAA-R tool can be used to monitor
response to treatment and adjust detox drug dose (appendix 1)
Please note that the detox regimen may require modification according to the
patient response. NICE recommends that the dose required to treat Alcohol
withdrawal might exceed the one recommended by the BNF in order to achieve
response. Therefore, patients should be assessed regularly and dose adjusted
(increased/reduced) or regimen changed according to response
Management of Acute Alcohol Withdrawal ULHT/G/214/546 A
CESC Approved March 2014
Review Date March 2016
3 of 8
Subsequent Management
Alcoholic patients are at high risk of malnutrition and should be referred
to dietician.
Those who are likely to have developed Wernicke’s with signs of
improvement but still having ataxia and confusion should continue on
IV pabrinex infusion for as long as physical symptoms persist or the
admitting clinician decide that further improvement is unlikely.
Patients admitted with alcohol-withdrawal seizure are not classed as
epileptics, and will not require long-term anti-convulsant therapy.
If detailed Alcohol intake history was not possible initially, it can be
taken once the patient stabilised and started to recover. Please use the
units measurements guide (appendix 2)
Discharge and Follow- Up
Patients should be discharged on Thiamine 100 mg OD and Vit B CoStrong 1 tab OD
All patients who underwent detox should be offered Alcohol cessation
advice and encouraged to contact:
Alcoholics Anonymous (AA) 01904 644026
Drugs and Alcohol Recovery Team (DART) Lincolnshire:
Boston
Babbage House, Rear of Boston
Borough Council, West Street,
Boston PE218QR
Tel: 01205 314479
Email: [email protected]
Grantham
Beaconfield Centre, Beacon Lane,
Grantham, NG31 9DF
Tel: 01476 591233
Email: [email protected]
Lincoln
Carholme Court, Long Leys Road,
Lincoln LN1 1FS
Tel: 01522 597979
Email: [email protected]
Management of Acute Alcohol Withdrawal ULHT/G/214/546 A
CESC Approved March 2014
Review Date March 2016
4 of 8
Appendix 1: ALCOHOL WITHDRAWAL MANAGEMENT FLOW CHART
Person in Acute Alcohol Withdrawal
and mimicking conditions excluded
Initial assessment of severity, including risk of developing
seizures or delirium tremens (for assessment of
withdrawal severity, use CIWAA-R Scale
Give thiamine (IV pabrinex 2 pairs of amp I&II) for prevention and
treatment of Wernicke’s.
Look for and correct any electrolyte abnormalities.
Monitor closely for hypoglycaemia and correct only under
pabrinex cover, to avoid precipitating Wernicke’s encephalopathy.
Manage withdrawal symptoms according to the severity of alcohol withdrawal
and continue to monitor patients using CIWAA-R withdrawal scale
MILD WITHDRAWAL
CIWAA-R Score <10
Reassure and refer to
local alcohol support
services, if available in
the community
If agitated and
treatment required
give 5-10 mg of
chlordiazepoxide 6-8
hourly for the 1st 24-48
hrs.
Monitor 4 hourly
MODERATE
WITHDRAWAL
CIWAA-R Score 10-19
SEVERE
WITHDRAWAL
CIWAA-R Score >20
Start chlordiazepoxide
at a dose of 20-30 mg 6
hourly and 10-20 mg to
be given as required to
achieve
symptom
control
Start chlordiazepoxide
at a dose of 40 mg 6
hourly and 10-20 mg
to be given as required
to achieve symptom
control
Monitor hourly for at
least the 1st 4-6 hours
while scoring 10-19 on
CIWAA-R
Monitor hourly while
scoring
>20
and
continue to give the
PRN dose to achieve
symptom control
For patients who develop delirium tremens, oral lorazepam should be offered and
if patient declined the oral medications, parenteral lorazepam, haloperidol or
olanzapine can be considered.
Recommended BNF max dose of chlordiazepoxide is 250mg/24hrs, but higher
doses may be required.
Benzodiazepines should be sufficient to control Alcohol withdrawal seizures
(phenytoin should NEVER be used to treat Alcohol withdrawal seizures).
All patients nutritional status should be assessed by a dietician and offered
dietary supplements if indicated.
Upon
discharge
following
clear information should
be provided
Management
of Acute Alcohol
Withdrawal successful
ULHT/G/214/546detox,
A
5 of 8
CESC
Approved March
2014their
Review
Date
March 2016support service providers.
to
patients
about
local
alcohol
Appendix 2: Guidance to Alcohol unit per drink (Measuring the units)
Drink Type
Volume
Strength
Units
568 ml
4.0%
2.3
Beer
Small bottle (330 ml)
5.0%
1.6
A pint of cider
568 ml
4.5%
2.6
Glass of wine
175 ml
13%
2.3
Glass of champagne
125 ml
12%
1.5
Spirit (single)
25 ml
40 %
1
A pint of beer
This is a guidance to calculate alcohol intake for individual patients, you can
also use the alcohol calculator tool available online on the following link:
http://www.nhs.uk/Tools/Pages/Alcohol-unit-calculator.aspx
Management of Acute Alcohol Withdrawal ULHT/G/214/546 A
CESC Approved March 2014
Review Date March 2016
6 of 8
Document Control
The Trust must be able to demonstrate that the documents are researched
and based on best practice and that all guidelines are audited and reviewed
therefore:
The following sections must be completed, with a clear statement of who will
be responsible for the dissemination, implementation and review of the
document?
Version History Log
This table should detail the version history for this document. It should detail
the key changes when a version is amended.
Version
1.
Date Implemented
February 2014
Details of key changes
New document
2.
Target Staff Group
Medical staff looking after patients admitted with Alcohol withdrawal
symptoms. Junior and senior doctors, nursing staff, dietitians.
Auditable Standards and Frequency
These guidelines were drafted in response to poor management/ prescribing
of acute alcohol withdrawal (detox regime), and once approved and
implemented, we will re-audit to check if the standards of care for patients with
Alcohol withdrawal have improved (e.g. assessment of withdrawal severity,
adequate dosing) and to make sure the guidelines recommended are being
followed
Implementation strategy
To be promoted through clinical governance meeting and the monthly audit
meetings.
Consultants to inform their junior doctors
Ward managers to inform nursing staff that the guideline is in use
Authors
Abdulfatah Masaud, Specialty doctor in Gastroenterology, department of
gastroenterology, Pilgrim Hospital.
Imad Wazir, CMT1 Doctor, Department of Gastroenterology, Pilgrim Hospital.
References:
1- Alcohol-use DISORDERs, THE NICE GUIDELINE ON DIAGNOSIS,
ASSESSMENT AND MANAGEMENT OFHARMFUL DRINKING AND
ALCOHOL DEPENDENCE, National Clinical Practice Guideline 115.
Published by: The British Psychological Society and The Royal College
of Psychiatrists 2011.
Management of Acute Alcohol Withdrawal ULHT/G/214/546 A
CESC Approved March 2014
Review Date March 2016
7 of 8
2- Sullivan, J.T.; Sykora, K.; Schneiderman, J.; Naranjo, C.A.; and Sellers,
E.M. Assessment of alcohol withdrawal: The revised Clinical Institute
Withdrawal Assessment for Alcohol scale (CIWA-Ar). British Journal of
Addiction 84:1353-1357, 1989.
3- www.bnf.org
Signature Sheet
Clinical Document Title: Management of Acute Alcohol Withdrawal
Date of Development: March 2014
NAME
SIGNATURE
Print Name
Dr Abdulfatah Masaud (Specialty
Doctor in Gastroenterology)
Signed
Abdulfatah Masaud
Anita Raj (Consultant
Gastroenterologist, Pilgrim)
email
Anita Raj
Richard Armstrong (Consultant email
Gastroenterologist, Pilgrim)
Richard Armstrong
Mike Perry (Consultant
Gastroenterologist, Pilgrim)
email
Michael Perry
Sathish Babu (Consultant
Gastroenetrologist, Lincoln)
Signed
Sathish Babu
DTC Approved March 2014 subject
to changes (now made)
Author(s) confirm that they have collected all the signatures, as listed
above, and posted to Clinical Governance Development Unit, Corridor F,
Grantham Hospital.
Chair of Clinical Effectiveness Steering Committee*
Management of Acute Alcohol Withdrawal ULHT/G/214/546 A
CESC Approved March 2014
Review Date March 2016
YES / NO
Jim Campbell
8 of 8
RECOGNITION AND ASSESSMENT:
Acute alcohol withdrawal can be the presenting feature leading to hospital
admission or can develop in a hospitalised patient who was admitted for other
unrelated health issues.
The term Acute alcohol withdrawal is used to describe the physical symptoms
that a person can experience when they suddenly reduce the amount of
alcohol they drink if they have previously been drinking excessively for
prolonged periods of time (NICE 2010).
Detailed history including the quantity, type and frequency of alcohol
intake as well as any medical and psychiatric co-morbidities should
be clearly documented in the admission proforma (Please refer to
appendix 2 of this document to help calculating the units)
SIGNS & SYMPTOMS:
These depend on the severity of withdrawal. The CIWAA-R score is attached
for more accurate assessment:
Mild Withdrawal or (CIWAA-R Score 0-9):
Mild tremors
Mild anxiety
Minimal sweating
Slight irritability
Mild Tachycardia 100-110 bpm
Low grade pyrexia (37.2-37.8)
Insomnia
Moderate Withdrawal or (CIWAA-R Score 10-19):
Noticeable tremor
Malaise
Marked anxiety
Agitation and excitability
Profuse sweating
Tachycardia >110 beats/min
Low grade pyrexia or fever.
Raised blood pressure
Management of Acute Alcohol Withdrawal ULHT/G/214/546 A
CESC Approved March 2014
Review Date March 2016
1 of 8
Severe Withdrawal or (CIWAA-R Score >20):
Same symptoms of moderate with progression to
Hallucinations (Visual or auditory)
Restlessness
Coarse tremor (that can affect even head and trunk)
Gait disturbances and ataxia
Pyrexia (>37.8°C)
Convulsions
Delirium Tremens (DT):
This is a severe form of withdrawal syndrome, which usually starts 48 to 72
hours after cessation of drinking and is characterized by coarse tremor,
agitation, irritability, fever, tachycardia, confusion, delusions and
hallucinations. DT is a medical emergency and untreated; carries a very high
mortality.
Wernicke’s encephalopathy:
This is a clinical syndrome that results from acute Thiamine deficiency and is
characterised by a triad of confusion, ataxia and ophthalmoplegia. Please
note that replacing Glucose in hypoglycaemic alcoholics without
Thiamine replacement can precipitate this syndrome. (See management
below).
Korsakoff’s syndrome:
This can be a progression from Wernicke’s if thiamine deficiency continues,
and is characterised by impaired memory, confusion and confabulation.
INVESTIGATIONS:
FBC
U&E, Magnesium (Patient with alcohol excess can be magnesium
deficient)
CRP (infection and sepsis can be missed in these patients, have a low
threshold for cultures as well)
Blood Glucose (Regular BMs)
LFT
Bone Profile (Patient with alcohol excess can have severe
hypophosphatemia)
Coagulation Profile
ABG (Particularly in severe withdrawal)
Management of Acute Alcohol Withdrawal ULHT/G/214/546 A
CESC Approved March 2014
Review Date March 2016
2 of 8
IMMEDIATE TREATMENT:
Assess severity of withdrawal using the CIWAA-r tool provided.
Correct electrolyte disturbances and hypoglycaemia. (DO NOT GIVE
Glucose until at least the first dose of pabrinex administered, to avoid
precipitating Wernicke’s)
Give Parenteral Thiamine in the form of pabrinex (TWO PAIRS OF
AMPOULES I&II) IV tds for at least the first 3 days of detox regimen.
This might need to be continued for longer in malnourished patients as
they are at high risk of developing Wernicke’s/Korsakoff.
Monitor BMs regularly (at least 4 hourly) during the first 24-48 hours
and 2 hourly if drowsy or confused.
Prescribe the adequate dose of chlordiazepoxide, depending on the
severity of withdrawal symptoms using the specific chlordiazepoxide
drug chart available online.
Make sure prn chlordiazepoxide 10-20 mg is prescribed in the patient’s
regular drug chart.
Prescribe Vit B Co Strong 1 tab OD
Patient Monitoring
HR, Blood Pressure, Temp, RR at least 4 hourly.
BMs 4hourly (2 Hourly in drowsy patients)
Assess for any behavioural instability or mode changes and clearly
document this in the notes. CIWAA-R tool can be used to monitor
response to treatment and adjust detox drug dose (appendix 1)
Please note that the detox regimen may require modification according to the
patient response. NICE recommends that the dose required to treat Alcohol
withdrawal might exceed the one recommended by the BNF in order to achieve
response. Therefore, patients should be assessed regularly and dose adjusted
(increased/reduced) or regimen changed according to response
Management of Acute Alcohol Withdrawal ULHT/G/214/546 A
CESC Approved March 2014
Review Date March 2016
3 of 8
Subsequent Management
Alcoholic patients are at high risk of malnutrition and should be referred
to dietician.
Those who are likely to have developed Wernicke’s with signs of
improvement but still having ataxia and confusion should continue on
IV pabrinex infusion for as long as physical symptoms persist or the
admitting clinician decide that further improvement is unlikely.
Patients admitted with alcohol-withdrawal seizure are not classed as
epileptics, and will not require long-term anti-convulsant therapy.
If detailed Alcohol intake history was not possible initially, it can be
taken once the patient stabilised and started to recover. Please use the
units measurements guide (appendix 2)
Discharge and Follow- Up
Patients should be discharged on Thiamine 100 mg OD and Vit B CoStrong 1 tab OD
All patients who underwent detox should be offered Alcohol cessation
advice and encouraged to contact:
Alcoholics Anonymous (AA) 01904 644026
Drugs and Alcohol Recovery Team (DART) Lincolnshire:
Boston
Babbage House, Rear of Boston
Borough Council, West Street,
Boston PE218QR
Tel: 01205 314479
Email: [email protected]
Grantham
Beaconfield Centre, Beacon Lane,
Grantham, NG31 9DF
Tel: 01476 591233
Email: [email protected]
Lincoln
Carholme Court, Long Leys Road,
Lincoln LN1 1FS
Tel: 01522 597979
Email: [email protected]
Management of Acute Alcohol Withdrawal ULHT/G/214/546 A
CESC Approved March 2014
Review Date March 2016
4 of 8
Appendix 1: ALCOHOL WITHDRAWAL MANAGEMENT FLOW CHART
Person in Acute Alcohol Withdrawal
and mimicking conditions excluded
Initial assessment of severity, including risk of developing
seizures or delirium tremens (for assessment of
withdrawal severity, use CIWAA-R Scale
Give thiamine (IV pabrinex 2 pairs of amp I&II) for prevention and
treatment of Wernicke’s.
Look for and correct any electrolyte abnormalities.
Monitor closely for hypoglycaemia and correct only under
pabrinex cover, to avoid precipitating Wernicke’s encephalopathy.
Manage withdrawal symptoms according to the severity of alcohol withdrawal
and continue to monitor patients using CIWAA-R withdrawal scale
MILD WITHDRAWAL
CIWAA-R Score <10
Reassure and refer to
local alcohol support
services, if available in
the community
If agitated and
treatment required
give 5-10 mg of
chlordiazepoxide 6-8
hourly for the 1st 24-48
hrs.
Monitor 4 hourly
MODERATE
WITHDRAWAL
CIWAA-R Score 10-19
SEVERE
WITHDRAWAL
CIWAA-R Score >20
Start chlordiazepoxide
at a dose of 20-30 mg 6
hourly and 10-20 mg to
be given as required to
achieve
symptom
control
Start chlordiazepoxide
at a dose of 40 mg 6
hourly and 10-20 mg
to be given as required
to achieve symptom
control
Monitor hourly for at
least the 1st 4-6 hours
while scoring 10-19 on
CIWAA-R
Monitor hourly while
scoring
>20
and
continue to give the
PRN dose to achieve
symptom control
For patients who develop delirium tremens, oral lorazepam should be offered and
if patient declined the oral medications, parenteral lorazepam, haloperidol or
olanzapine can be considered.
Recommended BNF max dose of chlordiazepoxide is 250mg/24hrs, but higher
doses may be required.
Benzodiazepines should be sufficient to control Alcohol withdrawal seizures
(phenytoin should NEVER be used to treat Alcohol withdrawal seizures).
All patients nutritional status should be assessed by a dietician and offered
dietary supplements if indicated.
Upon
discharge
following
clear information should
be provided
Management
of Acute Alcohol
Withdrawal successful
ULHT/G/214/546detox,
A
5 of 8
CESC
Approved March
2014their
Review
Date
March 2016support service providers.
to
patients
about
local
alcohol
Appendix 2: Guidance to Alcohol unit per drink (Measuring the units)
Drink Type
Volume
Strength
Units
568 ml
4.0%
2.3
Beer
Small bottle (330 ml)
5.0%
1.6
A pint of cider
568 ml
4.5%
2.6
Glass of wine
175 ml
13%
2.3
Glass of champagne
125 ml
12%
1.5
Spirit (single)
25 ml
40 %
1
A pint of beer
This is a guidance to calculate alcohol intake for individual patients, you can
also use the alcohol calculator tool available online on the following link:
http://www.nhs.uk/Tools/Pages/Alcohol-unit-calculator.aspx
Management of Acute Alcohol Withdrawal ULHT/G/214/546 A
CESC Approved March 2014
Review Date March 2016
6 of 8
Document Control
The Trust must be able to demonstrate that the documents are researched
and based on best practice and that all guidelines are audited and reviewed
therefore:
The following sections must be completed, with a clear statement of who will
be responsible for the dissemination, implementation and review of the
document?
Version History Log
This table should detail the version history for this document. It should detail
the key changes when a version is amended.
Version
1.
Date Implemented
February 2014
Details of key changes
New document
2.
Target Staff Group
Medical staff looking after patients admitted with Alcohol withdrawal
symptoms. Junior and senior doctors, nursing staff, dietitians.
Auditable Standards and Frequency
These guidelines were drafted in response to poor management/ prescribing
of acute alcohol withdrawal (detox regime), and once approved and
implemented, we will re-audit to check if the standards of care for patients with
Alcohol withdrawal have improved (e.g. assessment of withdrawal severity,
adequate dosing) and to make sure the guidelines recommended are being
followed
Implementation strategy
To be promoted through clinical governance meeting and the monthly audit
meetings.
Consultants to inform their junior doctors
Ward managers to inform nursing staff that the guideline is in use
Authors
Abdulfatah Masaud, Specialty doctor in Gastroenterology, department of
gastroenterology, Pilgrim Hospital.
Imad Wazir, CMT1 Doctor, Department of Gastroenterology, Pilgrim Hospital.
References:
1- Alcohol-use DISORDERs, THE NICE GUIDELINE ON DIAGNOSIS,
ASSESSMENT AND MANAGEMENT OFHARMFUL DRINKING AND
ALCOHOL DEPENDENCE, National Clinical Practice Guideline 115.
Published by: The British Psychological Society and The Royal College
of Psychiatrists 2011.
Management of Acute Alcohol Withdrawal ULHT/G/214/546 A
CESC Approved March 2014
Review Date March 2016
7 of 8
2- Sullivan, J.T.; Sykora, K.; Schneiderman, J.; Naranjo, C.A.; and Sellers,
E.M. Assessment of alcohol withdrawal: The revised Clinical Institute
Withdrawal Assessment for Alcohol scale (CIWA-Ar). British Journal of
Addiction 84:1353-1357, 1989.
3- www.bnf.org
Signature Sheet
Clinical Document Title: Management of Acute Alcohol Withdrawal
Date of Development: March 2014
NAME
SIGNATURE
Print Name
Dr Abdulfatah Masaud (Specialty
Doctor in Gastroenterology)
Signed
Abdulfatah Masaud
Anita Raj (Consultant
Gastroenterologist, Pilgrim)
Anita Raj
Richard Armstrong (Consultant email
Gastroenterologist, Pilgrim)
Richard Armstrong
Mike Perry (Consultant
Gastroenterologist, Pilgrim)
Michael Perry
Sathish Babu (Consultant
Gastroenetrologist, Lincoln)
Signed
Sathish Babu
DTC Approved March 2014 subject
to changes (now made)
Author(s) confirm that they have collected all the signatures, as listed
above, and posted to Clinical Governance Development Unit, Corridor F,
Grantham Hospital.
Chair of Clinical Effectiveness Steering Committee*
Management of Acute Alcohol Withdrawal ULHT/G/214/546 A
CESC Approved March 2014
Review Date March 2016
YES / NO
Jim Campbell
8 of 8
