Alcohol Withdrawal 🍺
Standard fixed-dose alcohol withdrawal regimen for ward patients: when to treat, chlordiazepoxide and lorazepam reducing doses, Pabrinex, haloperidol and monitoring. Based on the CUH regimen on eMed.ie.
🚨 When to treat
- Obvious withdrawal: CIWA-Ar >10, sweating, HR >100, hand tremor, agitation.
- Not in withdrawal but clear history: >10 units/day or previous withdrawal.
- In ED awaiting medical admission.
- CDU patients not suitable for symptom-triggered (CIWA) detox.
- This is the ward regimen. CDU uses symptom-triggered CIWA dosing.
💊 Chlordiazepoxide (Librium): oral, first line
- Max 250 mg in 24 h. Review the dose daily.
Day 1
- Regular
- 10–40 mg qds
- PRN
- 10–40 mg 2-hourly
Day 2
- Regular
- 10–40 mg qds
- PRN
- If needed
Day 3
- Regular
- 10–30 mg qds
- PRN
- If needed
Day 4
- Regular
- 10 mg qds
Day 5
- Regular
- 10 mg bd
Day 6
- Regular
- Stop
| Day | Regular | PRN |
|---|---|---|
| Day 1 | 10–40 mg qds | 10–40 mg 2-hourly |
| Day 2 | 10–40 mg qds | If needed |
| Day 3 | 10–30 mg qds | If needed |
| Day 4 | 10 mg qds | |
| Day 5 | 10 mg bd | |
| Day 6 | Stop |
💊 Lorazepam: oral, if liver failure
- Max 8 mg in 24 h. Review the dose daily.
Day 1
- Regular
- 1–2 mg tds
- PRN
- 1 mg 2-hourly
Day 2
- Regular
- 1–2 mg tds
Day 3
- Regular
- 1–2 mg tds
Day 4
- Regular
- Reduce by 1 mg/day
Day 5
- Regular
- Reduce by 1 mg/day
Day 6
- Regular
- Reduce by 1 mg/day
Day 7
- Regular
- Reduce by 1 mg/day
| Day | Regular | PRN |
|---|---|---|
| Day 1 | 1–2 mg tds | 1 mg 2-hourly |
| Day 2 | 1–2 mg tds | |
| Day 3 | 1–2 mg tds | |
| Day 4 | Reduce by 1 mg/day | |
| Day 5 | Reduce by 1 mg/day | |
| Day 6 | Reduce by 1 mg/day | |
| Day 7 | Reduce by 1 mg/day |
⚖️ Dosing
- Equivalence: diazepam 10 mg = chlordiazepoxide 25 mg = lorazepam 1 mg.
- Start dose on last 24 h symptoms or severity of dependence.
- Adjust daily to response.
- Lower doses if elderly, frail or low body mass.
- Abnormal LFTs, normal bilirubin, albumin and PT: chlordiazepoxide is fine.
- Liver failure: consider lorazepam.
🧠 Wernicke’s prophylaxis
- Give Pabrinex or IV thiamine before glucose.
- Then oral thiamine 200 mg daily (± multivitamin) while still at risk.
Pabrinex
- Dose
- 2 pairs of 5 mL ampoules IV q8h, 1–5 days
or IV thiamine
- Dose
- 500 mg IV q8h, 1–5 days
| Drug | Dose |
|---|---|
| Pabrinex | 2 pairs of 5 mL ampoules IV q8h, 1–5 days |
| or IV thiamine | 500 mg IV q8h, 1–5 days |
😵 Psychosis / delirium tremens
- Adjust chlordiazepoxide dose first.
- Haloperidol, no liver disease: 5 mg PO/IM 4-hourly PRN, max 30 mg/24 h.
- Haloperidol, liver disease: 0.5 mg PO/IM 2-hourly PRN, max 2 mg/24 h.
- Severe agitation: diazepam 10 mg IV over >5 min, or IV lorazepam.
- Violent or acutely disturbed: follow the acute behavioural disturbance guideline.
📋 Monitoring
- Vital signs, level of arousal, CIWA-Ar.
- Drowsiness is not alcohol withdrawal. Omit the dose and look for a cause.
- Watch for dehydration, hypoglycaemia, infection, head injury.
Based on
Educational reference only. Medical disclaimer