TABLE 2. Components of the CIWA-Ar11,18
because of their effectiveness in reducing the signs and symptoms of withdrawal, such as the incidence of seizure and delirium.8
Nausea and vomiting (0-7)
Tactile disturbances (0-7)
Tremor (0-7)
Auditory disturbances (0-7)
Paroxysmal sweats (0-7)
Visual disturbances (0-7)
Anxiety (0-7)
Headache (0-7)
Agitation (0-7)
Orientation and clouding of sensorium (0-4)
Scorea: <8: Very mild withdrawal; 8-14: Mild withdrawal; 15-20: Modest withdrawal; ≥20 Severe withdrawal a
Mild Symptoms For patients experiencing mild withdrawal symptoms (eg, CIWA-Ar score <8) who are at minimal risk of developing severe symptoms or complications of alcohol withdrawal, the ASAM recommends treatment with pharmacotherapy or supportive care alone. Carbamazepine or gabapentin are appropriate pharmacologic treatments for mild symptoms. For patients with mild symptoms who are at risk of developing new or worsening withdrawal while away from the treatment setting, the ASAM recommends use of benzodiazepines, carbamazepine, or gabapentin.8
Interpretation of cutoff scores for mild, modest, and severe vary by source.
Other scales that can be used to assess for the risk for severe alcohol withdrawal include8: • Luebeck Alcohol-Withdrawal Risk Scale (LARS) • Prediction of Alcohol Withdrawal Severity Scale (PAWSS) Although data collected from these assessments are extremely helpful in detection of alcohol withdrawal symptoms, the screening tools should be used as supportive measures in combination with the clinical picture as provided by a detailed history and thorough physical examination. Additionally, laboratory investigations such as urine drug screening, liver functions tests, blood alcohol levels, electrolyte levels, and a complete blood count are mainstays for establishing a diagnosis.17 Treatment Setting
The treatment setting is primarily determined by the severity of the withdrawal symptoms present.11 In patients presenting with mild to moderate withdrawal, outpatient detoxification is considered safe and effective.11,17 Although outpatient followup recommendations include seeing the patient daily until symptoms subside, treatment in this environment is cost effective, less burdensome on acute care hospitals, and minimizes interruptions on the patient’s personal life.11,17 An inpatient setting is warranted for patients who experience seizures or DTs or have severe withdrawal symptoms, abnormal laboratory results, or chronic medical or psychiatric conditions.8,17 Management of Alcohol Withdrawal Syndrome
Patients at risk of developing alcohol withdrawal syndrome (AWS) may be provided with preventative pharmacotherapy with benzodiazepines when attempting to reduce or stop alcohol intake, according to the 2020 ASAM guidelines on AWS. Benzodiazepines are first-line treatment for AWS prophylaxis
Moderate Symptoms Patients with moderate symptoms (eg, CIWA-Ar scores 8-20) should be treated with pharmacotherapy with benzodiazepines being the first-line treatment; carbamazepine or gabapentin are appropriate alternative therapies. Benzodiazepine may be used in combination with carbamazepine, gabapentin, or valproic acid (in patients without liver disease or childbearing potential).8 Severe Symptoms Patients with severe, but not complicated, withdrawal symptoms (eg, CIWA-Ar ≥20) should be treated with benzodiazepines or, as an alternative, phenobarbital (only use if the clinician is experienced with its use). Other options for patients with contraindications to benzodiazepine use include carbamazepine or gabapentin. Adjunctive agents may be used (eg, carbamazepine, gabapentin, and valproic acid).8 Risk for prolonged benzodiazepine use and misuse include memory impairment, psychomotor retardation, depression, and emotional anesthesia in addition to physiologic dependence.17 Because of the high addiction risk, alternative agents such as carbamazepine and gabapentin have less abuse potential, less toxicity, less sedation, and have demonstrated efficacy in the treatment of alcohol withdrawal syndrome.8 For ongoing management of AUD, the Department of Veterans Affairs and the Department of Defense recommends use of acamprosate, disulfiram, naltrexone (extended release), and/or topiramate (off-label) for the initial management of AUD.19 The American Psychiatric Association recommends first-line treatment of AUD with acamprosate and naltrexone, and use of disulfiram, gabapentin (off-label), and topiramate as second-line options.20 Gabapentin is beneficial for treating withdrawal symptoms in patients who will benefit from ongoing gabapentin use for treatment of AUD, according to the ASAM. Gabapentin (an
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