Alcohol Withdrawal Syndrome

Alcohol withdrawal begins 6–24 hours after last drink. Minor symptoms peak at 24–36h; seizures at 24–48h; delirium tremens (DTs) at 48–72h with peak mortality. Assess severity with CIWA-Ar score. All patients need Pabrinex (thiamine) to prevent…

CIWA-Ar / Chlordiazepoxide Protocol

The pathway

1 · CIWA-Ar assessment

Score: nausea/vomiting, tremor, sweating, anxiety, agitation, perceptual disturbances, headache, clouding of sensorium. Mild ≤8, moderate 9–15, severe ≥16. Repeat 4-hourly minimum.

2 · Wernicke's prophylaxis — MANDATORY

Three different situations, three different regimens (BNF):

Lower risk, eating normally: oral thiamine
Prophylaxis in assisted withdrawal as an inpatient: Pabrinex 1 pair OD IM for 5–7 days
Suspected or established Wernicke’s: Pabrinex 2–3 pairs TDS IV for 3–5 days, then 1 pair OD for a further 3–5 days

3 · Chlordiazepoxide protocol (front-loading)

Mild (CIWA ≤8): oral regimen starting 20–40mg QDS, reducing over 7 days
Moderate/severe (CIWA >8): larger doses with PRN top-ups
Lorazepam IV if cannot take oral (seizure risk)

4 · Seizure management

Alcohol withdrawal seizure: benzodiazepines (lorazepam 2–4mg IV) first-line. Do NOT use phenytoin (not effective for alcohol withdrawal seizures). Chlordiazepoxide regime may need increasing.

5 · Delirium Tremens (DTs)

DTs: acute confusion + autonomic instability (tachycardia, hypertension, fever, sweating). ITU if severe. High-dose benzodiazepines IV. Monitor electrolytes (hyponatraemia, hypomagnesaemia, hypophosphataemia). Mortality 5–15% if untreated.

6 · Monitoring & discharge

Daily CIWA-Ar. U&E, LFTs, Mg, phosphate. BM monitoring. Seizure precautions (no driving, no heights). Alcohol withdrawal can last 7–10 days. AUDIT-C for alcohol use disorder assessment. Refer to alcohol specialist services / community detox.

Drugs

Drug	Dose	Route	Notes
Pabrinex (IV thiamine)	Prophylaxis 1 pair OD; Wernicke’s 2–3 pairs TDS	IM (prophylaxis) / IV infusion (treatment)	Prophylaxis and treatment are different doses — 1 pair OD for 5–7 days in assisted withdrawal; 2–3 pairs TDS for 3–5 days if Wernicke’s is suspected. Anaphylaxis risk — give where resuscitation is available.
Chlordiazepoxide	10–40mg QDS + PRN 10–20mg	PO	Titrate to CIWA-Ar. Taper over 7 days. Avoid in liver failure (use lorazepam).
Lorazepam	1–4mg	IV/IM	If cannot take oral, or active seizure. Short-acting benzodiazepine.
Haloperidol	0.5–2mg	PO/IM	Adjunct for severe agitation in DTs. Does NOT treat withdrawal per se.

When to escalate

CIWA-Ar ≥16 or DTs — high-dependency environment,Seizure — benzodiazepines IV, consider ITU,Wernicke's encephalopathy (confusion, ataxia, ophthalmoplegia) — Pabrinex 2–3 pairs TDS IV for 3–5 days, senior review,Haemodynamic instability in DTs — ITU

Reference: NICE CG100 Alcohol-Use Disorders / BAP Guidelines 2018

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