bottle row

Alcohol Withdrawal

Alc WD Management
Alc WD Severity Scale
CIWA driven Sx Triggered

Benzodiazepine Pharmaco-kinetics

  • History of complicated withdrawal (delirium tremens, seizures, ICU admission)
  • At risk for severe or complicated alcohol withdrawal
  • Actively withdrawing despite high blood alcohol level
    • Actively withdrawing means CIWA>7
    • Discontinue prophylaxis once 6 CIWA scores concurrently <8
    • very concerning if high BAL and CIWA > 7
  • Delirium or encephalopathy
  • Benzodiazepine non-response or benzodiazepine resistance
  • Phenobarbital tends to be less deliriogenic
  • Excessive drinking results in the down-regulation of inhibitory GABA receptors
  • Down-regulation of GABA receptors leads to up-regulation of excitatory receptors to maintain homeostasis
  • Homeostasis regained until take alcohol away→ dysregulation of inhibitory + excitatory neurotransmitters
  • Super excitation of glutamate receptors created→ withdrawal symptoms
  • Phenobarbital is very predictable.
  • Using 10mg/kg IDW dose almost impossible to cause toxic level in absence of benzodiazeipines.
  • Determine risk of severe or complicated withdrawal syndrome→ PAWS scale
  • Determine risk of complications
    • Sedation→ > 65 yo, hepatic dysfunction, narcotics, head injury, recent sedatives
    • Respiratory compromise→ pneumonia, rib fractures, chest tube, contusion, C-collar/ brace
    • chronic issues not a concern (COPD, Asthma, OSA)
  • Algorithm will guide you to loading dose
  • Day 1: Loading Dose
    • 6-15 mg/kg IDW
    • one continuous IV infusion over 30 mins (may have to do in ED/ICU)
    • or Fractionated into 3 doses given IM every 3 hrs
  • Day 2-15: Taper
    • 64.8 mg PO twice daily x 2 days, then 32.4 mg PO twice daily x 2 days
    • does not have to be completed, if doing well can be stopped early
  • Give phenobarbital 65-130mgs IV/IM/PO every 1 hour as needed to achieve RASS goal of 0 to -1
  • not at risk of dose stacking due to fast onset
  • Max cumulative dose 20-30mg/kg- rare to get there, usually 10-15 mg/kg enough
  • use caution with <10mg/kg- few pts truly at high risk for mod-severe withdrawal that will get by on this dose
  • Consider adding non-GABA-ergic medication→ haloperidol
  • avoid benzodiazepines after this large loading dose
    • many programs use phenobarb+ benzos but only with smaller phenobarbital loading doses
    • once go down this road with phenobarbital, you will not be able to turn back
  • <72 hours
    • alcohol withdrawal seizures: 24-48 hrs
    • delirium tremens: 48-90 hrs
    • consider increasing dose of benzodiazepine, switching to IV or switching to phenobarbital
    • if guess wrong and decrease dose to soon, could put pt at higher risk of  these complications to develop
    • Goal RASS -1
  • >72 hours
    • consider benzodiazepine-induced delirium
    • reduce dose of benzodiazepine & add antipsychotic (risperidone, quetiapine, haloperidol)
    • look for other non-alcohol related causes
    • consider using gabapentin, valproic acid & clonidine if not 1st-line