Management of alcohol withdrawal

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NHS GGC

Assessment

Effective assessment is key to successful treatment.

If there is a suspicion of alcohol misuse prior to admission a formal assessment of the patient’s alcohol use must be undertaken (The FAST tool can aid assessment). 

Severity of Alcohol Dependence Questionnaire (SAD-Q) should be completed.

The completed SAD-Q will be filed in the patient’s care record and the score obtained will be entered on to the fixed dose Chlordiazepoxide regime.

Diazepam fixed regime

NICE guidelines recommend the use of fixed or symptom triggered dosing regimens with either chlordiazepoxide or diazepam to manage alcohol withdrawal.

In GG&C mental health services, diazepam is the drug of choice using a fixed dose regime. For patients with known liver impairment, oxazepam is the benzodiazepine of choice. (see chart on page 3-5). 

The starting dose chosen will depend on the SAD-Q obtained and the clinical judgement of the prescribing doctor.

Vitamin supplementation

Appropriate vitamin supplementation is essential to mitigate the risk of developing Wernicke’s encephalopathy or Korsakoff’s syndrome.

Wernicke’s Encephalopathy is an acute illness, which may be precipitated by alcohol withdrawal and is often under treated or missed.


If a patient presents with history of alcohol misuse and any of the following symptoms, this should be treated as a medical emergency:

  • Acute confusion
  • Ataxia/unsteadiness
  • Decreased consciousness
  • Unconciousness/coma
  • Unexplained hypotension with hypothermia
  • Opthalmoplegia/Nystagmus
  • Memory disturbance

Intramuscular Pabrinex (1 pair once daily for first 5 days) and oral thiamine should be given to all patients undergoing treatment for alcohol withdrawal.

Pabrinex is contraindicated if the patient is known to have an allergy to any of the components of the product or a previous reaction is noted.


MHRA/CHM advice (September 2007)
Although potentially serious allergic adverse reactions may rarely occur during, or shortly after, parenteral administration, the CHM has recommended that:
1. This should not preclude the use parenteral thiamine particularly in patients at risk of Wernicke-Korsakoff syndrome where parenteral treatment with thiamine is essential.
2. Facilities for treating anaphylaxis should be available when parenteral thiamine is administered.
Please note: Risk of anaphylaxis is very low 1/1 million i.v. and 1/5 million i.m. It is far lower than for other im/iv preparations administered without special cautions. All efforts should be made to ensure adequate vitamin B supplementation or consequently failure to do so can have life-long implications.

Thiamine should be prescribed as 50mg four times a day, due to absorption saturation giving large doses less often will result in poorer absorption.

Thiamine should be continued indefinitely for those with a history of significant alcohol abuse and in individuals who continue to engage in problem drinking (chronic alcohol reduces thiamine absorption and these individuals are particularly at risk of developing alcohol-related brain damage).

To help with long term adherence to thiamine:

  • Underline the importance of therapy
  • Encourage individuals to take thiamine as often as they remember e.g. take with meals
  • Where there is evidence of poor dietary intake, treatment with a multivitamin preparation containing trace elements should also be considered

Monitoring

The patient’s blood pressure, pulse and temperature should be monitored at 4 hourly intervals throughout treatment with close observation for over sedation.

The patient should be medically reviewed as necessary during the course of treatment.

Editorial Information

Last reviewed: 01/03/2024

Next review date: 01/03/2026

Author(s): Mental health service, PrescribingManagementGroup.MentalHealth@ggc.scot.nhs.uk.

Version: 2

Approved By: PMG-MH

Reviewer name(s): Lead Clinical Pharmacist, Clinical Effectiveness Pharmacist.