Alcohol Withdrawal Symptoms - The Management Of

Publication: 23/08/2007  --
Last review: 24/09/2019  
Next review: 24/09/2022  
Clinical Guideline
CURRENT 
ID: 6104 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2019  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

The management of alcohol withdrawal symptoms

  1. Detection of misuse
  2. Presentation of alcohol withdrawal syndrome
  3. Treatment of alcohol withdrawal Symptoms
  4. Wernicke’s encephalopathy (WE) or alcoholic encephalopathy
  5. Treatment for alcohol withdrawal as an outpatient
  6. Appendix 1

1. Detection of misuse

Studies have shown that 20-25% of patients admitted to hospital have an alcohol consumption that is in excess of sensible limits. An alcohol history should be taken in all patients admitted to hospital.

A number of questionnaires are available to detect alcohol misuse.
Briefly these establish:

  • Quantity drunk and whether others/ self have concerns
  • Dependency (eg. crave a morning drink)
  • Social problems (missed work)
  • Physical problems (head injury, fits etc)

Supporting evidence may come from examination. e.g. bruising, facial appearance and liver disease.
Laboratory markers can provide corroboratory evidence; however, none are sensitive or specific enough to be used in isolation.

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2. Presentation of alcohol withdrawal syndrome

When a patient drinks excess alcohol their central nervous system adjusts due to the constant presence of alcohol. Therefore when the blood alcohol level is suddenly lowered, the brain remains in a hyperactive and hyperexcited state causing the withdrawal syndrome.

Some patients are not troubled by alcohol withdrawal whilst 40% will develop an acute withdrawal syndrome upon stopping or significantly curtailing alcohol intake. The risk of withdrawal is not directly related to intake.

Using a Withdrawal scale is helpful. The scale can be used as a base-line against which withdrawal severity can be measured over time and can minimise over- and under- dosing with benzodiazepines.

See appendix 1

Uncomplicated alcohol withdrawal:
Results from increased autonomic activity, symptoms are seen within hours (typically 6 to 8) of the last drink and may develop before the blood alcohol level has fallen to zero.
Signs outlined below may vary in severity, commonly peaking at 10 to 30 hours

Tremor Sweating
Agitation Irritability
Anorexia and nausea Increased heart rate and BP
Fever Anxiety
Insomnia  

Hallucinations:
Seen in approximately 25% of hospitalised patients who have been heavy drinkers for at least 10 years. The onset is usually within 24hrs of the last drink. They are most often visual, although auditory hallucinations are common.

Alcohol related seizures:
Usually occur within 12 to 48 hours of alcohol cessation and may develop before blood level fallen to zero.

Severe alcohol withdrawal (delirium tremens):
Occurs in approximately 5% of patients undergoing alcohol withdrawal, but accounts for highest morbidity and mortality.
Onset is 2 to 5 days following cessation and represents a medical emergency.

Clinical features:

hallucinations clouding of consciousness
delusions confusion and disorientation
severe tremor tachycardia >100/min
agitation fever

If untreated death may result from respiratory and cardiovascular collapse or cardiac arrhythmias.

Pointers to severe alcohol withdrawal:
High alcohol intake >15units/day
Previous history of severe withdrawal
Use of other illicit drugs
Poor physical health
History of psychiatric illness
Hypoglycaemia
Hypokalaemia
Hypocalcaemia
Fever
Sweating
Insomnia
Tachycardia

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3. Treatment of alcohol withdrawal Symptoms

Non- Pharmacological treatment:
A supportive, non-threatening, calm, and well-lit environment is essential to help minimise the psychological distress associated with withdrawal

Pharmacological treatment:
Oral chlordiazepoxide is the preferred choice of benzodiazepine as it has long half life, low potency and lower potential for abuse than diazepam.
The dose should be tailored to each patient dependent upon severity of withdrawal symptoms. This avoids either under-treatment associated with patient discomfort and a higher incidence of complications such as seizures or DTs, or over-treatment, associated with excessive sedation and risk of toxicity/interaction with alcohol consumed prior to admission.

Using the CIAW-Ar (Appendix 1)

A score of < 10 on the CIWA-Ar score indicates mild alcohol withdrawal; this usually requires very small doses of chlordiazepoxide or none at all. Patients may just require symptomatic treatment e.g. paracetamol

A score 10 to 20 indicates moderate alcohol withdrawal. A typical regimen might be chlordiazepoxide 10-20mg four times daily, reducing gradually over 5 days.

A score > 20 indicates severe withdrawal. The dose prescribed should be within the range chlordiazepoxide 20- 40mg four times daily, reducing gradually over 5 days.

A total daily dose of 120mg chlordiazepoxide on day one is usually appropriate.
The maximum cumulative dose in 24 hours should not exceed 250mg without seeking expert advice.
Where possible information about previous response to chlordiazepoxide should be taken into account.

Chlordiazepoxide should be administered at regular 6 hourly intervals with additional prn dose available for breakthrough symptoms.
The total daily dose should be reduced to zero over a number of days. Patients should be assessed for withdrawal symptoms prior to each administered dose, and drug charts should be reviewed by medical staff at least daily.

Example:

Oral chlordiazepoxide reducing regimen

Day

Morning

Midday

Early evening

Night

(Total)

1

30mg

30mg

30mg

30mg

120mg

2

30mg

 

30mg

30mg

90mg

3

30mg

   

30mg

60mg

4

     

30mg

30mg

5

     

20mg

20mg

6

     

10mg

10mg

Breakthrough symptoms: chlordiazepoxide 5 mg to 10mg prn

Elderly (>80 years) or frail patients
Refer to LTHT management of alcohol withdrawal in older people, or consult your ward pharmacist.

Patients with liver failure
Chlordiazepoxide and diazepam should be avoided as these drugs are metabolised by the liver and can accumulate.
Lorazepam should be used as an alternative. 500 micrograms- 1mg orally every 6 hours to a maximum of 8mg/24 hours.
Contact liver team for advice.

Severely confused and agitated patients may be unable to take oral treatment.
Diazepam 10mg slow IV into large vein, at rate of not more than 5mg/minute, repeated if necessary after not less than 4 hours.
Lorazepam IV 1mg-2mg repeated after 6 hours if necessary
If IV access is a problem rectal diazepam (as solution, not suppositories) should be used, 500 micrograms/kg (up to a max of 30mg)
When oral or IV or PR not possible, can be via intramuscular route. Note, erratic absorption can occur when given via this route.

If patient remains agitated contact senior member of team or liaison psychiatry for further advice.

Treatment of Seizures
There is little evidence to support the use of conventional anti-epileptics in the prophylaxis or treatment of alcohol withdrawal related seizures

(Important to note, idiopathic generalised epilepsy patients may present for the first time with a seizure after alcohol, however these patients would not experience any other alcohol withdrawal symptoms- seek expert advice.)

Psychosis
Refer to Management of acute behavioural disturbances in adults guidance.

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4. Wernicke’s encephalopathy (WE) or alcoholic encephalopathy

WE is a reversible biochemical lesion of the CNS caused by overwhelming metabolic demands being made upon depleted B-vitamin reserves, in particular thiamine.
It occurs in 12.5% of alcohol misusers.
It may develop over a number of days. If inappropriately managed it is the primary or a contributory cause of death in 17% of patients and results in permanent brain damage (Korsakoff’s psychosis) in 85% of survivors.

Presentation:

  • acute confusion
  • ataxia
  • ophthalmoplegia (paralysis of eye muscles)

Classically described as a triad of signs, however all 3 only occur in 10% of patients.

Treatment of Wernicke’s encephalopathy if one or more signs of encephalopathy are present:-
Pabrinex IVHP 2 ampoule PAIRS three times a day for 3 days, then continue up to 7 days until improvement ceases.

Prophylaxis of Wernicke’s encephalopathy for patients with no symptoms of encephalopathy, but with known/suspected history of alcohol misuse and any of the following risk factors:-

  • Concurrent illness
  • Delirium tremens
  • Alcohol related seizures
  • IV glucose administration or requirement for IV glucose
  • Significant weight loss
  • Poor diet
  • Signs of malnutrition
  • Recent diarrhoea
  • Recent vomiting
  • Drinking greater than 20 units
  • Peripheral neuropathy

Pabrinex IVHP 1 ampoule PAIR daily for 3 to 5 days

Wernicke’s encephalopathy is initially reversible with parental thiamine so treatment should be initiated immediately a diagnosis is suspected or risk factors identified.

Parenteral thiamine administration is associated with a small risk of anaphylaxis. It should be given by infusion over 30min in 100ml 0.9% sodium chloride or 5% glucose. Facilities for treating anaphylactic reactions should be available.

In healthy uncomplicated heavy drinkers (i.e at low risk),
Oral thiamine 100mg three times a day should be given during detoxification (i.,e during hospital stay)

Oral thiamine supplementation
Oral thiamine should be given at discharge if the patient is malnourished or at risk or malnourishment, or is expected to continue drinking, or if they have decompensated liver disease. Prescribe thiamine 100mg three times a day which should be continued while the patient continues to drink excessive alcohol

Hypoglycaemia
Hypoglycaemia can occur in the withdrawal period as both malnutrition and liver disease impair the storage of glycogen. Blood glucose levels should be taken as necessary.
Refer to the LTHT hypoglycaemia guideline.

IV pabrinex must also be administered owing to the risk of precipitation of encephalopathy.

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5. Treatment for alcohol withdrawal as an outpatient

There are some instances where patients may be suitable for outpatient treatment for alcohol withdrawal. These are:

  • Mild – moderate alcohol withdrawal symptoms
  • No evidence of delirium
  • The patient is motivated and sensible
  • The patient understands not to drink alcohol whilst taking chlordiazepoxide

Outpatient treatment for alcohol withdrawal can occur when:

  • All the above points apply
  • The patient has had senior medical review.
  • When arrangements have been made for follow-up by the Leeds Addiction Unit or the patients GP.

In suitable cases, the medical team will prescribe enough chlordiazepoxide to last until the patient sees the Leeds Addiction Unit team or GP (usually 1- 2 days). The patient must be able to return to hospital if symptoms worsen.

Severe alcohol withdrawal requires in-patient treatment.

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6. Referral to primary care addiction services

Where possible, all patients who have been admitted for treatment of alcohol withdrawal should have an assessment during their hospital stay by Leeds Addiction Unit in reach. LAU can be contacted via Forward Leeds, tel. 0113 887 2477.

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Appendix 1

Adapted from the ‘Addiction Research Foundation Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar)’.

NAUSEA AND VOMITING - Ask "Do you feel sick to your stomach? Have you vomited?"
Observation.

0 - no nausea and no vomiting
1 - mild nausea with no vomiting
2
3
4 - intermittent nausea with dry heaves
5
6
7 - constant nausea, frequent dry heaves and vomiting.

TACTILE DISTURBANCES - Ask "Have you any itching, pins and needles sensations, or do you feel bugs crawling on or under your skin? Observation.
0 - none
1 - very mild itching, pins & needles, burning or numbness
2 - mild itching, pins & needles, burning or numbness
3 - moderate itching, pins & needles, burning or numbness
4 - moderately sever hallucinations
5 - severe hallucinations
6 - extremely severe hallucinations
7 - continuous hallucinations

TREMOR - Arms extended and fingers spread apart.
Observation.

0 - no tremor
1 - not visible, but can be felt fingertip to fingertip
2
3
4 - moderate, with patient's arms extended
5
6
7 - severe, even with arms not extended

AUDITORY DISTURBANCES - Ask "Are you more aware of sounds around you? Do they frighten you? Are you hearing things that you know aren't there?" Observation.-
0- not present
1 - very mild harshness or ability to frighten
2 - mild harshness or ability to frighten
3 - moderate harshness or ability to frighten
4 - moderately severe hallucinations
5 - severe hallucinations
6 - extremely severe hallucinations
7 - continuous hallucinations

PAROXYSMAL SWEATS - Observation.

0 - no sweat visible
1 - barely perceptible sweating, palms moist
2
3
4 - beads of sweat obvious on forehead
5
6
7- drenching sweats

VISUAL DISTURBANCES - Ask "Are you seeing anything that is disturbing you? Are you seeing things that you know aren't there?"
Observation.
0 - not present
1 - very mild sensitivity
2 - mild sensitivity
3 - moderate sensitivity
4 - moderately severe hallucinations
5 - severe hallucinations
6 - extremely sever hallucinations
7 - continuous hallucinations

ANXIETY - Ask "Do you feel nervous?" Observation.

0 - no anxiety, at ease
1 - mildly anxious
2
3
4 - moderately anxious, or guarded, so anxiety is inferred
5
6
7 - equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions

HEADACHE, FULLNESS IN HEAD - Ask “Does it feel like there is a band around your head?" Do not rate dizziness or lightheadedness.
Otherwise, rate severity.
0 - not present
1 - very mild
2 - mild
3 - moderate
4 - moderately severe
5 - severe
6 - very severe
7 - extremely severe

AGITATION - Observation.
0 - normal activity
1 - somewhat more than normal activity
2
3
4 - moderately fidgety and restless
5
6
7 - paces back and forth during most of the interview, or constantly thrashes about.

ORIENTATION AND CLOUDING OF SENSORIUM - Ask "What day
is this? Where are you? Who am I?

0 - oriented and can do serial additions
1 -cannot do serial additions or is uncertain about date
2 -disoriented for date by no more than two calendar days
3 disoriented for date by more than two calendar days
4 - disoriented for place and/or person

Maximum possible CIWA-Ar score is 67.
CIWA-Ar score <10 indicates mild alcohol withdrawal. Pharmacological treatment not necessary but supportive care required.
CIWA-Ar score 10 to 20 indicates moderate alcohol withdrawal. Pharmacological treatment not always necessary unless complicated by concurrent medical condition.
CIWA-Ar score >20 indicates severe withdrawal. Pharmacological treatment recommended.

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Provenance

Record: 6104
Objective:

This guideline is intended to provide guidance to practitioners within LTHT inexperienced in the field of dealing with alcohol withdrawal syndromes and to provide consistency in advice across the trust.

  • Recognition of all hospital attendees who drink excessively.
  • Identification of sub-groups with, or at risk of, potentially life-threatening complications
  • Prompt initiation of appropriate medical management.
  • Provide a tool to measure the severity of objective signs of withdrawal
  • Minimise morbidity and mortality and maximise patient comfort
Clinical condition:

Alcohol withdrawal

Target patient group: Any patient, admitted to hospital where medical/nursing staff have identified or suspect excess alcohol intake, excluding elderly patients (80 years or above).
Target professional group(s): Pharmacists
Secondary Care Doctors
Adapted from:

Evidence base

  1. A report of a Working Party of the Royal College of physicians. Alcohol - can the NHS afford it? Recommendations for a coherent alcohol strategy for hospitals. February 2001
  2. Nursing Council on Alcohol. The detection of alcohol misusers attending hospital and the management of alcohol withdrawal syndrome and Wernicke’s encephalopathy. An evidence based protocol.
  3. Cook C et al. B vitamin deficiency and Neuropsychiatric syndromes in alcohol misuse. Alcohol and Alcoholism; 33:317-336
  4. Rix KJB. Alcohol withdrawal States
  5. Mehta DK (Executive editor). British National Formulary July 2015. The British Medical Association and the Royal Pharmaceutical Society of Great Britain.
  6. Working Group on Mental Illness. The management of alcohol withdrawal and delirium tremens; a good practice statement. June 2004
  7. Hall W & Zador D. The alcohol withdrawal syndrome. Lancet 1997;349:1897-1900
  8. Taylor D, Paton C, Kerwin R. The South London & Maudsley NHS Trust Prescribing Guidelines 7th edition. (2003). Martin Dunitz Ltd, London
  9. Thomson A. Mechanisms of vitamin deficiency in chronic alcohol misuers and the development of the Wericke-Korsakoff Syndrome. Alcohol & Alcoholism 2000 : 35, suppl. 1 ;2-7
  10. Hutchinson TA, Shahn DR & Anderson ML (eds) Drugdex System Internet version Micromedex Inc. Greenwood Village, Colorado. Drug Therapy of ethanol withdrawal.
  11. Electronic Medicines Compendium. Datapharm Communication Ltd. http://emc.medicines.org.uk
  12. Sullivan JT et al. ‘Assessment of Alcohol Withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar)’. British Journal of Addiction 1989:84;1353-1357.
  13. Rubino F. Neurologic Complications of Alcoholism. The Interface of Psychiatry and Neurology 1992:15:2;359-371
  14. Cook C. Prevention and Treatment of Wernicke-Korsakoff Syndrome. Alcohol and Alcoholism. 2000:35;19-20
  15. Raistrick D. Management of alcohol detoxification. Advances in psychiatric treatment. 2000:6;348-355
  16. Holbrook A et al. Diagnosis and management of acute alcohol withdrawal. CMAJ 1999;160 (5)
  17. BAP Guidelines. Evidence-based guidelines for the pharmacological management of substance misuse, addiction and co morbidity; recommendations from the British Association For Psychopharmacology. Journal of Psychopharmacology 2004: 18(3)
  18. NICE full guidance. Alcohol use disorders: diagnosis and clinical management of alcohol-related physical complications. CG100 June 2010. www.nice.org.uk (accessed July 2015)

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

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