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(2) Withdrawal symptoms
Î Recommendation IV.16: Patients experiencing mild alcohol
withdrawal (e.g., CIWA-Ar score <10) who are at minimal risk of
developing severe or complicated alcohol withdrawal or complications
of alcohol withdrawal may be provided pharmacotherapy or supportive
care alone. If providing medication, carbamazepine or gabapentin
are appropriate options. For patients who are at risk of developing
new or worsening withdrawal while away from the treatment setting,
benzodiazepines, carbamazepine, or gabapentin are appropriate.
Î Recommendation IV.17: Patients experiencing moderate
alcohol withdrawal (e.g., CIWA-Ar scores 10–18) should receive
pharmacotherapy. Benzodiazepines are first-line treatment.
Carbamazepine or gabapentin are appropriate alternatives.
For patients with a contraindication for benzodiazepine use,
carbamazepine, gabapentin, or phenobarbital (in Level 2-WM
settings for providers experienced with its use) are appropriate.
Carbamazepine, gabapentin, or valproic acid (if no liver disease or
childbearing potential) may be used as an adjunct to benzodiazepines.
Î Recommendation IV.18: Patients experiencing severe, but not
complicated, alcohol withdrawal (e.g., CIWA-Ar ≥19) may be treated
in ambulatory Level 2-WM settings at the discretion of providers
with extensive experience in management of alcohol withdrawal.
Such patients should receive pharmacotherapy. Benzodiazepines are
first-line treatment. Phenobarbital is an appropriate alternative for
providers experienced with its use. For patients with a contraindication
for benzodiazepine use, phenobarbital, carbamazepine, or gabapentin
are appropriate. The use of adjunct medications is also appropriate.
Î Recommendation IV.19: If a patient is taking medication as prescribed
and symptoms are not controlled as expected:
• First, consider increasing the dose
If over-sedation or inadequate monitoring is a concern:
• Reassess for appropriate level of care
• Consider switching medications
• If using benzodiazepines, consider adding an adjunct medication
