See Also
1. Alcohol Withdrawal
Indications
1. Alcohol Dependence with tolerance and withdrawal risk
Contraindications
1. Comorbid illness necessitating inpatient management
  1. Serious cardiopulmonary conditions
  2. Uncontrolled Diabetes Mellitus
  3. Acute moderate to severe infectious illness
  4. Serious psychiatric illness (e.g. Suicidal Ideation)
2. Severe Alcohol Withdrawal (Stage 3, Delirium Tremens)
3. Unsafe environment
  1. Follow-up and contact difficult
  2. No reliable contact person to monitor patient
4. Comorbid Benzodiazepine Dependence
5. Prior failed outpatient detoxification
6. High risk for Delirium Tremens
  1. See Delirium Tremens for risk factors
Management: Symptom-Triggered Regimen (preferred)
1. Preferred over protocol below
2. Clinical Institute Withdrawal Assessment (CIWA-Ar)
  1. http://addiction-medicine.org/files/15doc.html
  2. Initially assess four times daily
  3. Assessment done by friend or family member
3. Select a Benzodiazepine
  1. Chlordiazepoxide (Librium) is preferred agent
4. Librium Protocol 1: FDA approved
  1. Initial: Librium 50-100 mg orally
  2. Repeat: Librium 50-100 mg orally up every 6 hours prn
    1. Outpatient Maximum: 300 mg daily
    2. Give Librium if symptoms suggest
      1. CIWA-Ar Score >8 points or
      2. Agitation not yet controlled
5. Librium Protocol 2: Not FDA approved
  1. Initial: Librium 25 to 100 mg orally
  2. Repeat: Librium 25 to 100 mg every hour prn
    1. Give Librium if CIWA-Ar Score >8 points
Management: Fixed Dose Protocol (Front-loading)
1. Diazepam (Valium) protocol (FDA approved)
  1. Day 1: 10 mg orally tid to qid
  2. Subsequent days: 10 mg orally tid to qid as needed
2. Chlordiazepoxide (Librium) protocol (not FDA approved)
  1. Not FDA approved
  2. Day 1: 50 mg every 6 hours for 4 doses
  3. Day 2-3: 25 mg every 6 hours for 8 doses
3. Oxazepam (Serax) protocol (FDA approved)
  1. Short-acting agent for liver disease and elderly
  2. Oxazepam 15 mg orally 3-4 times daily as needed
Management: Adjunctive medications
1. See Alcohol Withdrawal
Precautions: Medical supervision
1. Daily medical evaluation when CIWA-Ar >8
2. ER evaluation if Stage 3 Alcohol Withdrawal (DTs)
References
1. Blondell (2005) Am Fam Physician 71:495
2. Williams (1998) {a 18764} 33:103

Navigation Tree

Please see the Terms and Conditions. Please also see the privacy statement regarding advertising on this page. Although access to this page is not restricted, the information found here is intended for use by medical providers. Patients should address specific medical concerns with their physicians.

This page was written by Scott Moses, MD. This page was last revised before 5/10/08, prior to consistent tracking of revision date. This page was last published on 6/1/2008. Please send comments and questions to the editor. Contact information may be found on the page About the Family Practice Notebook. These pages are best viewed with Microsoft Internet Explorer 6.0.