ALCOHOL WITHDRAWAL

• Untreated, it carries a 15% mortality rate
• Occur as a presenting feature
• Occur as an unexplained development in a patient who has been admitted for other reasons and deprived of alcohol
• if frequent attendance at hospital (e.g. upper GI symptoms), pay particular attention
• Intoxicated patients with a high degree of tolerance towards alcohol may develop alcohol withdrawal symptoms
• even while their alcohol level may still seem high
• Mild withdrawal generally begins 6–8 hr after last drink, but can be sooner or considerably delayed
• Moderate-severe withdrawal occurs about 48 hr after last drink

Symptoms and signs

• Anxiety
• Sweating
• Tremor
• Ataxia
• Confusion

Assess severity

• Assess vital signs and record on NEWS chart
• Assess severity with Clinical Institute Withdrawal Assessment of Alcohol Scale (revised CIWA-Ar) form
• for advice on assessment, contact alcohol liaison nurse
• use CIWA-Ar in management below

Alcohol history

• Complete Alcohol screening tool (AUDIT)
• Quantity, frequency and highest daily alcohol use
• Previous treatment for alcohol misuse
• Previous abstinence
• Triggers for drinking
• Psychiatric problems
• Motivation

Investigations

Routine

• If decompensated alcoholic liver disease (ascites, encephalopathy) or a GI bleed, blood cultures
• FBC
• U&E
• LFT
• INR
• Bone profile plus magnesium and phosphate
• Blood glucose

Optional

• If severe withdrawal or severe systemic upset, arterial blood gases
• if illicit drug use suspected, urine drugs of abuse screen
• some of the newer drugs (‘legal highs’) may be difficult to identify
• Breath/blood alcohol
• Gamma-glutamyl transpeptidase test (GGT)

Differential diagnosis

• See Delirium (acute confusional state) in older people guideline
• Acute alcoholic hepatitis with hepatic encephalopathy
• Withdrawal of intoxication with drug(s) of misuse. See Withdrawal of drug(s) of dependence guideline

Alcohol related brain damage (ARBD)

• Alcohol related brain damage (ARBD) is an umbrella term
• spectrum of brain disorder including alcohol related dementia, alcohol amnesic syndrome and Wernicke-Korsakoff’s syndrome
• if left untreated can lead to irreversible brain damage, disorders of the nervous system and death
• If patient presents to ED appearing intoxicated, confused, ‘off legs’, consider ARBD
• Diagnosis is supported by the presence of the following:
• alcohol related hepatic, pancreatic, gastro-intestinal, cardiovascular or renal damage
• ataxia or peripheral neuropathy
• evidence on neuro imaging of brain atrophy

• The aim is to prevent features of withdrawal without over sedation
• If there is suspicion or evidence of alcohol dependence, monitor

Alcohol withdrawal in pregnancy

• Commence CIWA-Ar symptom assessment
• Discuss with alcohol liaison team, substance misuse midwife and alcohol management unit regarding tapered reduction of benzodiazepines

Monitor

• Check conscious levels, respiratory status and alcohol withdrawal symptoms
• look for other organic pathology
• If drowsy, confused or there is concern about previous readings, blood glucose 2-hrly
• Record CIWA-Ar score hourly for 8 hr (all patients)
• if CIWA-Ar score <8 on 2 consecutive readings, reduce assessments to 2-hrly. Continue for next 8 hr
• if CIWA-Ar score ≥8 on any reading, return to hourly assessments
• After 8 hours, if CIWA-Ar score <8 and not rising, reduce assessments to 4-hrly for next 48 hr
• then stop assessment unless CIWA-Ar score ≥8

Which sedative?

• Lorazepam and diazepam normally given orally
• Prescribe diazepam unless:
• patient is frail elderly, diazepam intolerant, showing signs of delirium tremens, in respiratory failure or severe liver impairment (e.g. INR >2 and bilirubin >200 or hepatic encephalopathy), then use lorazepam
• If patient usually on a regular benzodiazepine e.g. temazepam 10 mg at night, continue this with additional diazepam or lorazepam prescribed as required to manage alcohol withdrawal symptoms

Dose of sedative

• Administer as required medication as directed by CIWA-Ar assessments
• record doses given on drug chart and CIWA-Ar chart
• Individual dose requirements vary considerably
• decide only by monitoring and omitting or adding doses as necessary

CIWA-Ar score ≥16 on monitoring

• 10 mg diazepam or 1 mg lorazepam
• if severe withdrawal symptoms, some patients may require higher than BNF recommended limits of benzodiazepines

CIWA-Ar score 10-15 on monitoring

• 5 mg diazepam or 0.5 mg lorazepam

CIWA-Ar score <10 on monitoring

• No need for withdrawal medication 

Parenteral thiamine

• Most effective when given parenterally as oral absorption is poor
• Prefer IV route but if not available, use IM route
• Give Pabrinex IV high potency injection 2 pairs of ampoules (mixed) by IV infusion in sodium chloride 0.9% 100 mL over 30 min 8-hrly
• if IV route not available, give 1 pair of ampoules deep IM into gluteal muscle 12-hrly. Use Pabrinex preparation specific to IM injections

Treatment duration

• If decompensated liver disease, malnourishment/significant weight loss, memory disturbance, risk of Wernicke’s encephalopathy, continue Pabrinex for 72 hr
• If Wernicke’s encephalopathy is suspected or confirmed and physical symptoms persist beyond 72 hr but patient is improving symptomatically, give 1 pair of ampoules IV or deep IM once daily for as long as symptoms continue to improve for a minimum of 5 days
• In all other patients 72 hr of Pabrinex is not essential
• e.g. if patient medically fit for discharge within this time, do not continue

Fluids and electrolytes

• Monitor and replace electrolytes, magnesium and phosphate
• Give adequate hydration. See Adult fluid management guideline
• defer glucose infusions until after first dose of Pabrinex given as it can precipitate Wernicke’s encephalopathy

Criteria to discuss with senior medical staff

• Patient has required 3 mg lorazepam or 30 mg diazepam over 3 hr
• CIWA-Ar score >35
• Evidence of Delirium Tremens, a medical emergency

Referral

• If patient scores 11–12 on AUDIT-C or requires CIWA-Ar monitoring, refer to alcohol liaison team

Admission criteria

• Confusion or hallucinations
• Epilepsy or history of fits
• Undernourished
• Severe vomiting or diarrhoea
• Uncontrollable withdrawal symptoms
• Acute physical illness requiring admission
• Decompensated liver disease

Critical care discussion

• Total dose of lorazepam has reached 8 mg and patient still agitated
• Respiratory depression
• Patient in state of extreme agitation

Not for admission

• Advise patient to avoid sudden reduction in alcohol intake
• Refer to alcohol liaison team or give information on local alcohol support services
• Give a dose of Pabrinex IV as per guidance
• If the patient is observed in the ED, continue Pabrinex IV 8-hrly

Reassess patient

• If withdrawals persist, consider changing from diazepam to lorazepam
• If unable to tolerate oral benzodiazepines, or symptoms of severe hallucinations or agitation, consider use of parenteral lorazepam 1 mg (preferably IV into a large vein) with interval between doses of at least 15 min (IV) and 30 min (IM)
• do not use IM route in patients with bleeding/clotting disorders
• Haloperidol 1–5 mg can be added to enhance sedative effects of benzodiazepines
• see BNF for contraindications

Seizures

• Manage seizures, see First seizure guideline and Cluster seizures guideline
• However, withdrawal seizures alone do not signify epilepsy and maintenance anticonvulsant therapy is unnecessary 

• Where possible, liaise with alcohol liaison nurses to plan discharge
• Ensure all patients have been assessed for alcohol dependency with the AUDIT alcohol screening tool

Screening results (AUDIT score)

• <8: no action required
• 8–19: advice and offer referral to community alcohol services
• 20+: refer to alcohol liaison nurse

Drugs on discharge

• Prescribe oral thiamine 100 mg 8-hrly for all patients on discharge
• advise GP via discharge letter to continue this for 3 months in the community
• Do not start discharged patients on vitamin B compound
• in those admitted on vitamin B solely for the reason of alcohol dependency stop unless malnourished
• If patient malnourished refer to dietitian and discuss need for ongoing vitamin supplementation
• Alcohol liaison team may advise prescribing Acamprosate:
• body weight ≥60 kg – 666 mg 8-hrly
• body weight <60 kg – 666 mg at breakfast, 333 mg at midday and 333 mg at night
• to be continued on discharge and reviewed by GP or community alcohol service

Driving

• Advise patient to contact the DVLA and car insurance provider
• with alcohol related illness, they should not drive for 6 months
• with alcohol withdrawal, they should not drive for 12 months