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CIWA Protocol: Fraser Health
Rajwant Minhas
Pharmacy Resident
Overview
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Introduction: Alcohol Withdrawal
Timeline (pictures, graph)
Overview of CIWA Protocol
Scoring
Drugs we use
Why? Why not Phenytoin
How much? How long?
Why are labs ordered and how to interpret them?
Patient Case: typical patient and course of treatment
DRPs that could come up
Handout
DART resolution
Alcohol Withdrawal
Diagnostic Criteria
A. Cessation of (or reduction in) alcohol use that has been heavy and prolonged.
B. Two (or more) of the following, developing within several hours to a few days after criterion A:
1. Autonomic hyperactivity (e.g., sweating or pulse rate greater than 100
beats per minute)
2. Increased hand tremor
3. Insomnia
4. Nausea or vomiting
5. Transient visual, tactile, or auditory hallucination s or illusions
6. Psychomotor agitation
7. Anxiety
8. Grand mal seizures
C. The symptoms in criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.
Acute Alcohol Withdrawal
• Clinical features follow the cessation of
regular high-dose alcohol ingestion as
soon as blood alcohol level decreases
significantly
• Within 6-24 hours after stopping drinking,
tremors, nausea and vomiting, anxiety,
mild agitation, tachycardia, hypertension,
insomnia and diaphoresis may occur.
Symptoms usually peak b/w 24-36 hours
and may dissipate after 48 hours.
• Hallucinations occur in 3%–10%
• of patients and are usually visual; their
onset and duration are variable but
typically begin after several days of
abstinence.
Convulsions, which are usually 1 or 2 grand
• mal seizures, occur in 5%–15% of patients
during acute alcohol withdrawal and
typically occur within 6 to 48 hours after
alcohol cessation
• Alcohol consumption is more strongly
associated with seizures than is alcohol
withdrawal.
• Delirium tremens (disorientation and
global confusion) occur in < 5% of
patients, usually 3-5 days after withdrawal,
and last for 2-3 days.
• The overall rate of death from delirium
• tremens is estimated at 2%–10%, with
death usually due to cardiovascular,
• Basic laboratory investigations include a
complete blood count, liver function tests,
a urine drug screen, and determination of
blood alcohol and electrolyte levels.
Routine care
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Abnormalities in fluid levels, electrolyte levels, or nutrition should be
corrected. Intravenous fluids may be necessary in patients with severe
withdrawal because of excessive fluid loss through hyperthermia, sweating,
and vomiting. Intravenous fluids should not be administered routinely in
patients with less severe withdrawal, because these patients may become
overhydrated.
Routine administration of magnesium sulfate has not been shown to
improve withdrawal symptoms,9 but supplementation is appropriate if a
patient is hypomagnesemic. Multivitamins and thiamine (100 mg per day)
should be provided during treatment for alcohol withdrawal. If intravenous
fluids are administered, thiamine (100 mg intravenously) should be given
before glucose is administered, to prevent precipitation of Wernicke’s
encephalopathy.
Clinical Institute Withdrawal
Assessment
• 10 item scale
• Likert-type scale (0–7 in most cases)
• Maximum possible total score = 67
– Mild withdrawal: <15 or less
– Moderate withdrawal:16 and 20
– Severe withdrawal: >20
• To quantify the severity of alcohol withdrawal syndrome,
and to monitor and medicate patients going through
withdrawal
• Symptom triggered regimen for medication
administration
• Alcohol enhances the effect of GABA on
GABA-A neuroreceptors, resulting in
decreased overall brain excitability.
Chronic exposure to alcohol results in a
compensatory decrease of GABA-A
neuroreceptor response to GABA,
evidenced by increasing tolerance of the
effects of alcohol.
• Medications used are cross-tolerant with
alcohol
• Alcohol inhibits NMDA neuroreceptors, and chronic
alcohol exposure results in up-regulation of these
receptors. Abrupt cessation of alcohol exposure
results in brain hyperexcitability, because receptors
previously inhibited by alcohol are no longer
inhibited. Brain hyperexcitability manifests clinically
as anxiety, irritability, agitation, and tremors. Severe
manifestations include alcohol withdrawal seizures
and delirium tremens.
Thiamine
• Thiamine deficiency reported in 30-80% of patients with alcohol
dependance
• To prevent Wernicke’s encephalopathy
• This vitamin should be administered before intravenous glucose
because it is a cofactor necessary for glucose metabolism. Severe
and irreversible cerebellar and brain-stem damage has been
reported when glucose was administered to patients suffering acute
alcohol withdrawal who were not given concomitant thiamine
therapy.
• The value of multivitamin or other B
• vitamin prophylactic therapy for patients in alcohol withdrawal
remains unproven.
• Mild withdrawal: supportive care
Benzodiazepines
• Keystone therapy for alcohol withdrawal
• Sedating and anticonvulsant effects
• Shown to be safe and effective for seizure
prevention and treatment
• Diazepam (Valium) and chlordiazepoxide (Librium) are long-acting
agents that have been shown to be excellent in treating alcohol
withdrawal symptoms. Because of the long half-life of these
medications, withdrawal is smoother, and rebound withdrawal
symptoms are less likely to occur. Lorazepam (Ativan) and
oxazepam (Serax) are intermediate-acting medications with
excellent records of efficacy. Treatment with these agents may be
preferable in patients who metabolize medications less effectively,
particularly the elderly and those with liver failure. Lorazepam is the
only benzodiazepine with predictable intramuscular absorption (if
intramuscular administration is necessary).
• One randomized controlled trial (RCT)19 affirmed previous findings
that carbamazepine is an effective alternative to benzodiazepines in
the treatment of alcohol withdrawal syndrome in patients with mild to
moderate symptoms. Patients in the study received 800 mg of
carbamazepine on the first day, with the dosage tapered to 200 mg
by the fifth day. Carbamazepine (Tegretol) also appears to decrease
the craving for alcohol after withdrawal. It is not sedating and has
little potential for abuse. Although carbamazepine is used
extensively in Europe, its use in the United States has been limited
by lack of sufficient evidence that it prevents seizures and delirium.
Findings of Meta-Analysis
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All of the benzodiazepines studied appear to have similar efficacy.
Start treatment with benzodiazepines early, as indicated by the
CIWA-Ar score, rather than waiting for withdrawal to advance.
Use adequate doses
High doses are required to counteract the tolerance that most
people with alcohol dependence have to benzodiazepines.
• Higher doses given early, along with close monitoring using the
CIWA-Ar scale, are considered safe and may avoid the late sedation
that occurs with ongoing administration of lower doses.
• Phenytoin has not been demonstrated to
be superior to placebo in the prevention of
simple withdrawal-induced seizures
• but may be required for multiple recurrent
• seizures or focal seizures or in patients
with a history of epilepsy or head trauma.
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References
• Holbrook AM et al. Diagnosis and
management of acute alcohol withdrawal.
CMAJ 1999;160:675-80.
• Bayard et al. Alcohol Withdrawal
Syndrome. Am Fam
Physician. 2004 Mar 15;69(6):1443-1450.