The CIWA-Ar objectifies severity of alcohol withdrawal.
There are four stages of alcohol withdrawal. Stages 1, 2 and 3 are early alcohol withdrawal and symptoms will be present within 24 to 72 hours of decrease or cessation of alcohol consumption.
Stage 4, which is delirium tremens, is a late syndrome that does not manifest until three-to-five days after cessation. “That timing differentiation is very important for clinicians to determine what’s wrong with a patient,” Birnbaumer said.
Locally we use the Glasgow Modified Alcohol Withdrawal Scale (GMAWS), which allows us to monitor the patient’s symptoms. The scale advises a dose of diazepam based on which symptoms are present, and their severity. If a patient does have a withdrawal seizure (which is not self-terminating) it is treated with benzodiazepines.
If a patient has an elevated serum ethanol level, never assume the pt cant be in alcohol withdrawal. Those who heavily drink and those who drink nearly every day can start withdrawing at non-zero ethanol levels.
While benzodiazepines are the optimal treatment for AWS, there is debate regarding which benzodiazepine is best. No single benzodiazepine has been shown to be superior.
Phenobarbital, propofol, and dexmedetomidine have been shown to reduce benzodiazepine requirements in AWS.
ETOH withdrawal begins 6-8 hours after last intake and peaks in 72 hours
The DSM5 criteria are currently the gold standard for withdrawal. The CIWA-Ar score should not be used for diagnosis – the syndrome it describes is non-specific. Inappropriate application of the CIWA-Ar score to a patient not in withdrawal may lead to adverse events including over sedation and misdiagnosis.3
Benzodiazepines are used to treat the symptoms of alcohol withdrawal. Diazepam is often preferred since it is long-acting. Chlordiazepoxide is also a popular agent given it is long-acting and is thought to be less addictive. However, lorazepam may be preferable in those who metabolize the drug more slowly including the elderly and those with advanced liver disease. Lorazepam has a shorter half-life and therefore, its active metabolites are less likely to reach toxic levels
The goal of treatment is to reduce the severity of symptoms and prevent progression to delirium tremens.
It is widely accepted that the best way to treat alcohol withdrawal in hospitalized patients is with symptom triggered benzodiazepine therapy. Such treatment results in equivalent outcomes and less benzodiazepine use compared with scheduled benzodiazepine therapy.
The first line medication for treating patients with alcohol withdrawal is benzodiazepines. The drug of choice is diazepam because it has a long half-life of ~100 hours, and carries a decreased risk of developing serious withdrawal symptoms once the patient is discharged. Diazepam also has a faster onset of action than lorazepam. It is important to remember that diazepam should be avoided in patients with overt liver failure or a history of liver failure.
Even though more than half a million patients are seen in U.S. emergency departments for alcohol withdrawal each year, this seemingly straightforward diagnosis is missed more often than we may believe.1 Even when it is picked up, it is often mismanaged. Why?
There are numerous (perhaps innumerable) reasonable ways to treat alcohol withdrawal. Prior to the ~1970s, barbiturates were front-line agents. Following a push by pharma to market newly developed benzodiazepines, this shifted to benzodiazepines. This transition wasn't based upon any evidence that benzodiazepines deserved to be front-line agents, but rather perhaps the perception that benzodiazepines were newer and therefore must be better. Currently, the pendulum is swinging back to barbiturates. Those lacking a historical perspective will view benzodiazepines as conventional front-line therapy, but in the larger context of medical history the use of benzodiazepines for alcohol withdrawal may wind up having been a mistake.
common and can be fatal.
manifests within 48 hours of stopping drinking.