24
Treatment – Inpatient
Î Recommendation V.17: Patients experiencing severe alcohol
withdrawal (e.g., CIWA-Ar scores ≥19) should receive pharmacotherapy.
Benzodiazepines are first-line treatment. For patients with a
contraindication for benzodiazepine use, phenobarbital is appropriate
for providers experienced with its use. If close monitoring is available,
phenobarbital can be used as an adjunct to benzodiazepines. Other
adjunct medications can be considered after a clinician ensures that
an adequate dose of benzodiazepines has been administered.
Î Recommendation V.18: If a patient's 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 medication
• If using benzodiazepines, consider adding an adjunct medication
(3) Benzodiazepine use
Î Recommendation V.19: While no particular benzodiazepine agent is
more effective than another, longer-acting benzodiazepines are the
preferred agents due to clinical benefits from their longer duration of
action.
Î Recommendation V.20: If waiting for lab test(s) results or if the test(s)
are unavailable, if a patient has signs of significant liver disease, use a
benzodiazepine with less hepatic metabolization.
Î Recommendation V.21: Clinicians should monitor patients taking
benzodiazepines for signs of over-sedation and respiratory depression.
Î Recommendation V.22: A benzodiazepine prescription to treat alcohol
withdrawal should be discontinued following treatment.
(4) Benzodiazepine dosing regimens
Î Recommendation V.23: Symptom-triggered treatment is the preferred
benzodiazepine dosing method. Fixed dosing according to a scheduled
taper may be appropriate if symptom-triggered treatment cannot be
used.
Î Recommendation V.24: Front loading is recommended for patients
experiencing severe alcohol withdrawal (e.g., CIWA-Ar scores ≥19).
Diazepam or chlordiazepoxide are preferred agents for front loading.
Î Recommendation V.25: When using a fixed-dose schedule, patients'
signs and symptoms should still be monitored, and additional doses of
medication provided as needed.
