Management

Management 1- symptom triggered scoring systems

NICE recommends using a symptoms triggered treatment regime for management of AWS⁹ in the acute setting. These use scoring systems which assess the severity of the patient’s symptoms and guide dosage/frequency of pharmacological therapy. In the UK benzodiazepines, particularly diazepam, are the mainstay of treatment of AWS.   These exert there effect by potentiating the activity of GABA which aims to restore balance between GABA/NDMA⁸.

Management 20 CIWA-Ar and GMAWS 

Examples of symptom triggered scoring systems are the CIWA-Ar:

And the Glasgow Modified Alcohol Withdrawal Scale (GMAWS)¹⁶:

Essentially the more severe the symptoms the larger the dose of benzodiazepines and the more frequently the patient should be reassessed.  Typical doses would be 10-20mg of Diazepam (or 1-2mg of Lorazepam) with repeat scoring in 1-2 hours. 

Management 3- Pharmacological therapy 

NICE does not offer specific guidelines on special groups however the GMAWS protocol suggests¹⁰:

• Using lorazepam in patients with alcoholic liver disease (ALD) due to its shorter half life and potential reduced risk of oversedation
• Reduced benzodiazepine doses in patients with co-morbidities (COPD, reduced GCS, CVD, pneumonia, age >70, head injury and pregnancy). Reduce the dose by 50%.
• In patients unable to tolerate oral intake use an IV benzodiazepine at 50% of the oral dose (delivered by experienced staff and with appropriate monitoring for IV sedation)

Pitfall

There are significant differences between time half life and doses of different benzodiazepines.  Generally speaking diazepam and chlordiazepoxide are thought of as long acting and lorazepam short acting. 

Equivalent Doses: Diazepam 10mg= Lorazepam 1mg= Chlordiazepoxide 25mg¹⁶

Management 2 CIWA-Ar and GMAWS

A small subset of patients AWS will go on to develop severe AWS/DT. The rate of this is poorly defined in the literature with the incidence stated in the literature ranging from 8-33%^19,20. These patients can be violent and difficult to manage. NICE and the GMAWS protocol both recommend using parenteral benzodiazepines followed by parenteral haloperidol as a second line treatment^9,16. This treatment should only be delivered by clinicians experienced in IV sedation. These patients are at high risk of over sedation and complications and will likely require close observation and one to one nursing care.

Other treatments for benzodiazepine refractory AWS have been described in the literature such as phenobarbitoal^21,22, dexometamadine^23,24 and ketamine²⁵ however none of these are currently in widespread use in the UK. 

A small subset of patients will require mechanical ventilation and IV propofol infusions due to the severity of their symptoms²⁶.