20th February 2024

Investigation and treatment

The diagnosis of alcohol withdrawal depends on taking a good history from the patient and identifying the physical signs of alcohol withdrawal and co-morbidities secondary to alcohol use. The Clinical Institute for Withdrawal Assessment for alcohol revised scale (CIWA-Ar) is the tool used to help clinicians identify and stratify the severity of a patient’s alcohol withdrawal syndrome. The scoring system utilises the following symptoms as part of their scoring system: 

• Nausea and vomiting
• Tremor
• Sweats
• Anxiety
• Agitation
• Tactile disturbance
• Auditory disturbance
• Visual disturbance
• Headache/Fullness in the head
• Orientation

Points are given depending on the severity of each symptom, and a score is provided to indicate the severity of the withdrawal syndrome. Each hospital will have its cut-off for beginning treatment for alcohol withdrawal, and each clinician will refer to their local hospital guidance for the treatment threshold. A CIWA score of <8 typically represents mild symptoms, 9-15 for moderate symptoms and >15 for severe symptoms. 

The main goal of treatment is to control the patient’s autonomic dysfunction and reduce the risk of seizures. The mainstay of treatment for alcohol withdrawal is benzodiazepines. The choice of benzodiazepine is dependent on local guidance, but typically, diazepam and chlordiazepoxide are commonly used. This can be administered on a fixed schedule, or the patient’s symptom burden can guide this. Refractory alcohol withdrawal and seizures can be managed with phenobarbital and propofol, but this requires support in an intensive care setting. 

Basic supportive care for nutrition and hydration should also be provided. It is essential to watch for refeeding syndrome if there are suspicions that the patient may have had an inadequate diet for the days/weeks leading to readmission. Intravenous vitamin B complex is also given as a prophylaxis against Wernicke’s encephalopathy and patients are usually commenced on oral thiamine after completing their IV treatment. Follow-up with the substance misuse team, along with advice for abstinence from alcohol, should always be provided, and patients should be advised to reduce or stop their alcohol intake where possible.