Suddenly stopping alcohol intake in patients who have been drinking heavily for prolonged periods is dangerous and can lead to severe withdrawal. Delirium tremens can occur in about 10% of patients with withdrawal and carries a 5-10% mortality risk. Certain patients will require pharmacological (and non-pharmacological) tools as part of an inpatient alcohol detoxification programme, to achieve abstinence safely.

As an FY1 consider alcohol withdrawal in patients with any of the symptoms below or if they are self-discharging.

Symptoms of alcohol withdrawal (think autonomic overstimulation):
  • Tremor
  • Agitation
  • Anxiety
  • Hallucinations
  • Sweating
  • Vomiting
  • Seizures
  • Tachycardia
  • Nausea
  • Anorexia
  • Diarrhoea
These symptoms & signs overlap with those seen in other medical conditions which can make it easy to miss other diagnoses and simply label them as “withdrawal”. Always take a thorough history & full examination including for injuries, particularly to the head. Review when the patient last drank and consider an alcohol level on admission – if this is elevated it suggests the patient might not yet be in withdrawal and other diagnoses need to be more strongly considered. Never discharge a patient whilst they are still intoxicated.

Indications for admission
If the patient is going to resume drinking immediately despite all your best efforts, admitting them for a detox may unfortunately not be helpful. These patients may even drink whilst undergoing a detox regime in hospital which could heavily sedate them.

Indications include:
  • A past history of complicated withdrawals (seizures or delirium)
  • Current symptoms of confusion or delirium
  • Comorbid mental/physical illness, polydrug misuse, or suicide risk
  • Symptoms of Wernicke–Korsakoff syndrome
  • Severe nausea/vomiting; severe malnutrition
  • Lack of a stable home environment
  • Delirium tremens
  • Wishes to stop drinking 
As an FY1, you should discuss the patient and their symptoms with your seniors, who will be able to help you decide whether the patient needs an assisted withdrawal.

Treatment for withdrawal
In the first instance, you should follow your trust guidelines, but we will provide some information so you can understand the underlying principles.

It is better to have a very low threshold for treating alcohol withdrawal with regular medications (rather than PRN only medications). Patients who are withdrawing may be missed and if left may become agitated and/or hallucinating at which point it is very difficult to control the situation. There are accounts in many hospitals of patients absconding, being violent or causing harm to themselves whilst agitated which could be prevented by a regular regimen. The risk of harm from an inappropriate reducing medication regimen is minimal.

The most common treatment regimen is a reducing or weaning regimen of benzodiazepines. Some places use a symptom-triggered medication regimen. Although anticonvulsants (e.g. phenytoin, carbamazepine) are a recognised alternative by NICE, they do not reach therapeutic level until after the period of maximal risk. Chlordiazepoxide has a lower potential for abuse than diazepam therefore is preferred. Its active metabolites with long half-lives result in a very slow, smooth wean even for those taking it intermittently. The initial PRN doses supplement this initial peak level rather than simply treating symptomatically, therefore a weaning PRN dose isn’t necessary.

In patients with cirrhosis or liver failure, chlordiazepoxide should be used with caution.  Your trust will likely recommend the use of alternative benzodiazepines (oxazepam, lorazepam) in these cases.

NICE provides guidance on a Chlordiazepoxide dosing regimen on page 7. The CIWA (Clinical Institute Withdrawal Assessment for Alcohol) can be used to guide treatment which can be calculated here. Nursing observations and CIWA should be performed and monitored at least every two hours for the first 24 hours.

Additional treatment
IV Pabrinex should also be used to treat or avoid Wernicke’s encephalopathy.  Pabrinex comes in pairs of ampoules.  Each pair of ampoules consists of one 5 ml and one 2 ml ampoule, labelled as Pabrinex No. 1 and Pabrinex No. 2.  Patients will require either one or two pairs of ampoules, three times a day, depending on their presentation (refer to your trust guideline).  Depending on trust guidelines this is usually switched after a few days to vitamin B co strong & Thiamine orally.

Remember that the pharmacological treatment is only one aspect; patient requiring alcohol detox will often have other issues that will need to be addressed.  All patients should be referred to the inpatient alcohol/drug liaison team, and some may require referral to the psychiatric liaison team or social workers.  Be aware of the patient’s social surroundings outside of the hospital and address each issue appropriately.

Most importantly, remember to maintain an empathetic, calm and non-judgemental approach to ensure the patient is provided with kind and supportive treatment.

Written by Caio Redknap FY2