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In this section : Alcohol Withdrawal
Alcohol Withdrawal
Home | Articles | Alcohol Withdrawal | Alcohol Withdrawal

Alcohol Withdrawal

Last updated 29th October 2024

As of 29th October 2024 Pabrinex is no longer available.  For the time being, we are recommending the use of intravenous Thiamine instead.  See below.

Summary Flowchart

For guidance on thiamine in refeeding syndrome see Guidance on thiamine replacement in patients at risk of Refeeding Syndrome

Inpatient referrals

  1. Refer to Addiction Liaison Service via Cortix or by phoning 33090
  2. Patients should be aged 18 or over and medically fit to be seen and engage with service
  3. Patients with alcohol withdrawal and suicidal ideation or significant mental health issues should be referred to Acute Liaison Psychiatry as well as Addiction Liaison Service
  4. Patients discharged before they can be seen by Addiction Liaison eg at weekends should be given number for NHS Drug and Alcohol Service – 01387 244555
  5. Patients presenting with cannabis/cocaine/other recreational drug use rather than alcohol withdrawal should be referred to Addaction for follow up following discharge – 01387 263208 (Dumfries) or 01776 705907 (Stranraer).

Alcohol Withdrawal Syndromes

  1. Alcohol withdrawal usually begins within 6-8 hours after an abrupt reduction in heavy drinking
  2. Can be earlier in severe dependence or may not manifest for up to 72 hours
  3. Can develop before the blood alcohol level has fallen to zero.
  4. Generally peaks within 10-30 hours and lasts for 3-7 days

Alcohol Withdrawal Syndromes

No symptoms
- In up to 60% heavy drinkers who stop suddenly
Uncomplicated Withdrawal Symptoms
- Tremor, sweating, flushing, insomnia, nightmares, anxiety, vomiting, diarrhoea
Delirium Tremens
- A medical emergency. Onset usually 305 days following cessation // symptoms as above plus
- Confusion, agitation, aggressive behaviour, clouding of consciousness, hallucinations (mainly visual but may be tactile or auditory), delusions, tachycardia >100min, fever (with or without infection).
Alcohol Withdrawal Seizure
- Usually generalised and within 12-48 hours cessation. Rare beyond 48 hours.
- Hypoglycaemia, hypocalcaemia, hypomagnesaemia and history of epilepsy all predispose
- May be only manifestation of withdrawal
Wernicke's encephalopathy
- Classic triad of confusion with ataxia and ophthalmoplegia present in 10% cases only
- Diagnose if any one or more of the triad present in the absence of another more probable explanation
- Permanent brain damage including Korsakoff's psychosis may occur if inappropriately managed.

Assessment and General Management

  1. Calculate alcohol intake- see below
  2. Screen for dependence – FAST score – see below
  3. Assess severity of withdrawal using Glasgow Modified Alcohol Warning Score (GMAWS) – see below
  4. Look for stigmata of chronic liver disease
  5. Consider other possible causes of confusion in an alcohol dependent patient – see below
  6. Check FBC, U&E, LFTs including GGT & AST, BG, CaPO4, Mg and coag screen, blood alcohol level may also be useful.
  7. Maintain 2-2.5litres intake per day using IV if necessary
  8. Ensure good lighting and cool ambient temperature, good ventilation, supportive nursing, reassurance, single room if confused
  9. Consider ear plugs if difficulty sleeping (can be sourced from H@N Nurses)
  10. Prescribe Pabrinex and Benzodiazepines as per protocol

Possible Causes of Confusion in an Alcohol Dependent Patient

  1. Acute alcohol intoxication
  2. Alcohol withdrawal including Delirium tremens
  3. Hypoglycaemia
  4. Head injury
  5. Subdural haematoma
  6. Wernicke’s encephalopathy
  7. Hepatic encephalopathy
  8. Septicaemia
  9. Meningitis including TB meningitis
  10. Concurrent illicit substance abuse.

Calculating Alcohol Intake

Alcohol by Volume (ABV%)Average Units (ABV% x Vol)Formulae
Strong Lager 9% (440ml)4.0Number of Units = ABV (%) x Volume (litres)
eg a bottle of wine (750ml) which is 12% ABV = 12 x 0.75 = 9 units
a glass of wine (200ml) which is 12% ABV = 12 x 0.2 = 2.4 units


Estimated Weekly Alcohol Units:
Daily Units x number of days/week

Excessive Weekly Consumption:
Men and Women > 14 units/week
Beer/Lager 4.5% (Pint/500ml Can/Bottle)2.2
Wine (eg Buckfast) 15% (750ml)11.0
Wine (Table) 12% (750ml)9.0
Wine (Table) 12% (175ml glass)2.1
Alcopops 5% (330ml)1.5
Spirits 40% (25ml measure)1.0
Spirits 40% (1/4 bottle 175ml)7.0
Spirits 40% (Litre)40.0
Spirits 40% (700ml)30.0
Cider 4% (Litre)4.0
Cider 4% (440ml)1.8
Strong White Cider 8% (Litre)8.0
Strong White Cider 8% (330ml Glass)2.4

Fast Alcohol Screening Tool – FAST

CriteriaScore
NeverLess than monthlyMonthlyWeeklyDaily (or almost daily)
How often do you have 6 or more drinks on one occasion?0 - Stop screening1234
How often during the last year have you been unable to remember what happened the night before because you had been drinking?01234
How often during the last year have you failed to do what was normally expected of you because of drinking?01234
NoYes, not in the last yearYes, in the last year
In the last year has a friend or relative, or a doctor or other health worker been concerned about your drinking or suggested you cut down?024
NB 1 drink = 1 Unit of alcohol

What to do about the FAST Score

  1. FAST score 0-2: No action required
  2. FAST score 3-8: Advise regarding safe drinking levels and offer information leaflet/advice.
  3. FAST score 9-16: Probable dependent drinking.  Advice as above and consider referral to Alcohol Liaison Nurse.

Glasgow Modified Alcohol Warning Score (GMAWS) Screening Tool

CriteriaScoreCriteriaScoreCriteriaScore
Tremor
0) No tremor
1) On movement
2) At rest
Hallucination
0) Not present
1) Dissuadable
2) Not dissuadable
Agitation
0) Calm
1) Anxious
2) Panicky
Sweating
0) No sweat visible
1) Moist
2) Drenching sweats
Orientation
0) Orientated
1) Vague, detached
2) Disorientated, no contact
Total Score

Symptom Triggered GMAWS Management

Score & administration: (DO not use scoring tool if patient intoxicated, must be at least 8 hours since last drink).
GMAWS ScoreTreatmentRescore afterHigher risk groups
0NIL2 hoursRepeat score in 2 hours
1-310mg Diazepam2 hours1mg Lorazepam + rescore every hour
4-820mg Diazepam1 hour2mg Lorazepam + rescore every hour
≥920mg Diazepam1 hour2mg Lorazepam
discuss with medical staff regarding management of severe as per guideline

Fixed Dose Diazepam Regimen

Time from admissionDiazepam dose
Initial 24 hours20mg six hourly
If after 24 hours no additional symptom triggered treatment required or if after 48 hours GMAWS <4 then reduce as follows15mg six hourly for 24 hours
10mg six hourly for 24 hours
5mg six hourly for 24 hours
5 mg 12 hourly for 24 hours then stop
Review prescription if excessively drowsyMaximum of 120mg in 24 hours before requesting senior medical review

Use Lorazepam for Higher Risk Groups

  1. Patients with evidence of liver disease, especially jaundice, ascites, encephalopathy
  2. Patients with other co-morbidities eg COPD, pneumonia, cerebrovascular disease, head injury, reduced GCS, elderly over 70 years, head injury.
  3. Patients with co-prescribed CNS sedative drugs eg opiates
  4. Use oral lorazepam in these groups in a symptom-triggered fashion: 1-2mg to a maximum of 12mg in 24 hours before requesting senior medical review. Give IM or SC if unable to swallow.
  5. Patients on lorazepam may require more frequent monitoring and PRN doses due to shorter half life

Aggressive/uncontrollable/dangerous behaviour

    1. Move patient to Critical Care
    2. Follow dosing schedule for IV diazepam or IV lorazepam in table below
      Patient with severe or decompensated lver disease/respiratory disease/head injury?
      NO
      YES
      Diazepam emulsion (Diazemuls®) via large vein
      Lorazepam IV
      5mg
      1mg
      Insufficient/no response after 5-10 min
      5mg
      1mg
      Insufficient/no response after 5-10 min
      10mg
      2mg
      Insufficient/no response after 5-10 min
      10mg
      2mg
      Insufficient/no response after 5-10 min
      20mg
      2mg
      Insufficient/no response after 5-10 min
      Continue as above at 20mg doses
      Continue as above at 2-4mg
      If response not achieved at 120mg diazepam (or 12mg Lorazepam) seek senior medical advice & consider Haloperidol 3-5mg IM every 30-60minutes (max 18mg/24hours)
      Once settled continue at 5-20mg diazepam (1-2mg Lorazepam) every hour to maintain light somnolence
    3. Have flumazenil available
    4. Diazepam 120mg or lorazepam 12mg over 24 hours is unlikely to cause problems in an uncomplicated patient
    5. Consider adjunctive therapy with haloperidol 3-5mg IV or IM (smaller doses unlikely to be effective) if still not settling (minimum 4 hourly, max 12-18mg/24 hours)
    6. Once settled continue 5-20mg diazepam (1-2mg lorazepam) per hour to maintain light sedation
    7. Consider need for glucose and magnesium, but do not give glucose until after Pabrinex.
    8. In extreme cases where very high dose parenteral diazepam >200mg is ineffective it may be necessary to incubate.

Patients Unable to Tolerate Oral Medication

  1. Patients unable to tolerate oral medication may receive IV therapy (Diazemuls or lorazepam) as an alternative at 50% of the oral dose in the first instance and response assessed.
  2. It is recommended that IV benzodiazepines are administered by an experienced member of staff (FY2 or above).

Monitoring

  1. All patients should be closely observed for signs of oversedation
  2. Higher risk groups (see above), patients with severe withdrawal and patients requiring intravenous or intramuscular sedation require close monitoring (pulse, blood pressure, respiratory rate, GCS, oxygen saturation), ideally with one-to-one nursing care.
  3. Consultation regarding intensive care support may be necessary in extreme situations.
  4. If patient is only on symptom triggered GMAWS and is scoring 3 or less after 72 hours then symptom triggered treatment can be stopped

Approximate Oral Benzodiazepine Equivalence

  1. 10mg diazepam = 1mg lorazepam = 30mg chlordiazepoxide.

Medication on Discharge

  1. Do not discharge on regular benzodiazepine unless arrangement confirmed with community addiction services or Alcohol Liaison Nurse.  See Hippo (link below) for advice on discharging detox patients.
  2. Chlordiazepoxide is the recommended benzodiazepine for community use.
  3. All patients should go home on Thiamine 50mg qds.

Content updated by Alison Moore & Chris Isles