Management of Alcohol Withdrawal Syndrome

Relevant to:
All clinical staff involved in prescribing and administering medications to patients with
alcohol withdrawal symptoms.

Purpose of Protocol:
This policy has been introduced to ensure continuity of care between the community
services and the Trust in relation to the management of alcohol withdrawal syndrome.

Protocol to Follow:
Assessment for the Management of Alcohol Withdrawal Syndrome
1.1 When conducting an initial assessment, as well as assessing alcohol misuse, the
severity of dependence and risk, consider the:
 extent of any associated health and social problems
 need for assisted alcohol withdrawal
1.2 Use formal assessment tools to assess the nature and severity of alcohol misuse:
 Fast alcohol use screening test (FAST) – this is a quick test to assess risk of
alcohol harm (Appendix 1).
 Alcohol use disorders identification test (AUDIT) – this can be used to assess risk
of patient coming to harm from alcohol. For use in emergency department to
identify patients and refer to the alcohol liaison nurse (Appendix 2).
 Clinical Institute Withdrawal Assessment of Alcohol Scale, revised (CIWA-Ar) for
severity of withdrawal– this should be used to determine the severity of current
withdrawal symptom (Appendix 3).

Using the CIWA-Ar scale:

CIWA-Ar score 8-10

CIWA-Ar score 0-8 PRN chlordiazepoxide, but
No need for treatment, monitor symptom 2-4
monitor 4 hourly hourly and if >10 start
reducing dose

CIWA-Ar score >20

CIWA-Ar score10-20
Start on the reducing dose
Start on the reducing dose
of chlordiazepoxide from
of chlordiazepoxide from
30mg QDS (see below)
20mg QDS (see below)

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Reducing dose of Chlordiazepoxide

2.1 CIWA-Ar score 10-20

Time Day 1 Day 2 Day 3 Day 4 Day 5

06:00 20mg 15mg 10mg 5mg 5mg
12:00 20mg 15mg 10mg 5mg
18:00 20mg 15mg 10mg 5mg
22:00 20mg 15mg 10mg 5mg 5mg

2.2 CIWA-Ar score >20

Time Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

06:00 30mg 30mg 20mg 15mg 10mg 5mg 5mg
12:00 30mg 20mg 20mg 15mg 10mg 5mg
18:00 30mg 20mg 20mg 15mg 10mg 5mg
22:00 30mg 30mg 20mg 15mg 10mg 5mg 5mg

Note:
 PRN chlordiazepoxide should be prescribed as 10mg to 20mg, maximum dose of
100mg/24hr
 For patients on regular reducing dose of chlordiazepoxide, maximum daily dose
should not exceed 200mg/24hrs with PRN doses.

Exclusion criteria for using chlordiazepoxide

3.1 Do not use in the following exceptional patient groups:

 Elderly Patients
 Head Injury
 Patient with evidence of liver disease, especially jaundice, encephalopathy.
 Patients with significant co-morbidity i.e. COPD, pneumonia, cerebrovascular
disease, reduced GCS).

3.2 Lorazepam (oral) should be used in this group of patients.

Dose: 1-2mg as required 1-2 hourly.
Maximum of 12mg in 24 hours before requesting senior medical review.

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 Management of Alcohol Withdrawal Syndrome
Severe Withdrawal

4.1 This is defined as aggressive, uncontrollable and dangerous behaviour.

4.2 Prescribe IV diazepam administered via a large vein.

Dose: British National Formulary dosing for acute alcohol withdrawal is 10mg IV as
an initial dose. Dose may be repeated no sooner than 4 hours after, however doses
of up to 40mg may be required in the first 30 minutes. Doses greater than 10mg IV
are an unlicensed dose for this indication.
Rate of injection: maximum rate of 5mg/min

4.3 Monitoring: All patients should be closely observed for signs of over sedation with
regular observation. All patients requiring intravenous or intramuscular sedation
require close monitoring (NEWS) and ideally with one-to-one nursing care.
Consultation regarding intensive care support may be necessary in extreme
situations. All the patients should be transferred to Gastroenterology wards

4.4 It is recommended that IV benzodiazepine are administered by experienced staff

(Registrar or above).

4.5 If nursing staff administer IV benzodiazepines they MUST have competed the
appropriate competency training to administer IV sedation.

4.6 If patient is still aggressive and not responding, adjunctive therapy with haloperidol 5-
10mg intramuscularly (IM) can be given as smaller doses unlikely to be effective.

4.7 If there is still no improvement, ITU need to be contacted for consideration of agents
such as propofol.

4.8 Flumazenil must be available on the ward and prescribed if required.

Patients unable to tolerate oral medication

5.1 Patients unable to tolerate oral medication may receive an IV dose of diazepam or
lorazepam as alternative. Give 50% of the oral dose in the first instance and assess
response.
5.2 All patients should be closely observed for signs of over sedation with regular
observations.
5.3 For exceptional patient groups, patients with severe withdrawal and patients
requiring IV/IM benzodiazepines; close monitoring with regular NEWS at 1 – 4 hourly
intervals is always required. Ideally with one-to one nursing care.
Consultation regarding intensive care support may be necessary in extreme
conditions.

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 Management of Alcohol Withdrawal Syndrome
6 Vitamin Prophylaxis and Treatment of Wernicke-Korsakoff Encephalopathy

Assess the risk of Wernicke’s encephalopathy

Does the patient have any of the following signs /symptoms?
▪Confusion/agitation ▪Nystagmus
▪Ataxia ▪Decreased consciousness
▪Opthalmoplegia ▪Hypothermia/hypotension

YES NO

Overt/ incipient Wernicke’s Does the patient have 2 or

encephalopathy more of the following
YES signs/symptoms?

• MUST Score ≥ 2
• Malnourished
Pabrinex IV, • Weight loss/ / poor diet
At risk of Wernicke’s
2 pairs of vials three • Diarrhoea
encephalopathy • Vomiting
times daily for 3
days.

N.B. Check for and

correct
hypomagnesaemia Pabrinex IV NO
2 pair of vials once daily for three
days. (Or until confusion resolves –
Then step down to whichever is longer) Low risk of Wernicke’s
encephalopathy

Then step down to Thiamine oral 100mg

three times daily

Important notes
Patients with overt/ incipient Wernicke’s encephalopathy or ‘at risk’ of Wernicke’s encephalopathy must be given
Pabrinex® before the administration of glucose or nutritional support.
 Intravenous Pabrinex® should be administered over 30 minutes
 Anaphylaxis is a rare complication of IV Pabrinex® administration. Monitor patient for wheeze, tachycardia,
breathlessness and skin rash. Facilities for the administration of adrenaline and other resuscitation should be
available.
 Further vitamin supplementation as clinically indicated by responsible medical team in the context of a
general nutritional assessment e.g. Thiamine 100mg twice a day, Vitamin B Co Strong 1 three times a
day
 Acamprosate will be considered by Turning point
 Nalmefene is currently under review 1

1
Nalmefene can be prescribed via turning point who also provide the PSI targeted pathway – this
can be discussed with the Alcohol Liaison Nurse prior to discharge assessment
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 Management of Alcohol Withdrawal Syndrome
Discharge
 At discharge patients should NOT be given more than24 hours’ worth of
chlordiazepoxide. However if patients are discharged during the weekend, it may be
necessary to give doses to cover until Monday before presenting to Turning point or
Forward.
 All patients should be referred at discharge to Turning Point (Medway) or Forward
Trust (Swale and Sittingbourne).
 GPs will not supply any alcohol withdrawal treatment.
 Patients that arrive at Turning Point before 4pm will be seen that day. After 4pm
they will be seen the next working day.
 Please distribute Turning Point contact details via an information flyer to patients
(Appendix 4).
 For Sittingbourne and Swale Patients, either refer to the Alcohol Liaison Nurse and
she will pass to the appropriate service or contact them directly on 01795 411780.
 Patients with significant end organ damage (severe liver disease and severe
pancreatitis) should be considered for rehabilitation via referral to Turning Point.

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 Management of Alcohol Withdrawal Syndrome
Implications of not following Protocol
There is a risk to the safety of these patients both during and after discharge if this protocol
is not followed.

Useful Contacts:
Turning Point (423 High Street Chatham ME4 4NU) Telephone number(s): 01634 820390;
0300 123 1560
Forward Trust 01795 411780

Monitoring the Process:

This protocol will be reviewed in line with the Trust’s policy review program.
MMG will monitor the implementation and effectiveness of this guideline

National Definitions:
Hazardous drinking: A pattern of alcohol consumption that increases someone’s risk of
harm. Some would limit this definition to the physical or mental health consequences (as in
harmful use). Others would include the social consequences. The term is currently used by
the World Health Organization (WHO) to describe this pattern of alcohol consumption. It is
not a diagnostic term.
Harmful drinking: A pattern of alcohol consumption that is causing mental or physical
damage
Alcohol dependence: A cluster of behavioural, cognitive and physiological factors that
typically include a strong desire to drink alcohol and difficulties in controlling its use.
Someone who is alcohol dependent may persist in drinking, despite harmful consequences.
They will also give alcohol a higher priority than other activities and obligations

Reference Material & Associated Documents:

National Institute for Health and Care Excellence. Alcohol-use disorders: Diagnosis and
clinical management of alcohol-related physical complications. Clinical guideline [CG100].
Last updated April 2017.

National Institute for Health and Care Excellence. Alcohol-use disorders: diagnosis,
assessment and management of harmful drinking (high-risk drinking) and alcohol
dependence. Clinical guideline [CG115]. February 2011.

British National Formulary. Edition 79. BMJ Group and Pharmaceutical Press. March 2020.

Management of moderate and severe alcohol withdrawal syndromes – UpToDate. Last

updated July 2020.

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Appendix 1:

Fast Alcohol
Screening Tool.docx

Appendix 2:

Alcohol use disorders

identification test (AUDIT).docx

Appendix 3:

CIWA-Ar
assessment.docx

Appendix 4:

Turning Point
Flyer.pdf

Approval Signatures:
Revision No: 2 ID No: PROCMM004
Distribution: Intranet
Date Approved: 3/9/20
Approved By: Medicine Management Group
Review date: August 2022
Dr Mohamed Saleh, Clinical Lead Hepatology
Author(s): Ola Olabintan, Registrar Hepatology
Bukky Francis, Lead Pharmacist Medicine
Document Owner: Stephen Cook, Chief Pharmacist

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