Alcohol withdrawal: assess and treat
Adult who has stopped or cut down heavy drinking. Pregnant or under 18: get specialist advice now.
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Internal MedicineManagement
Alcohol Withdrawal Syndrome Management (CIWA-Ar)
Alcohol Withdrawal Syndrome Management (CIWA-Ar): Alcohol withdrawal: assess and treat → Wernicke encephalopathy? Treat on suspicion → All patients: thi...
Pathway Overview
21 steps
Algorithm Steps
21 total
01Start 02Warning Wernicke encephalopathy? Treat on suspicion
Confusion, ataxia, eye signs, coma, memory loss, low temperature with low BP, or delirium: treat as established, even if intoxicated.
- Suspected Wernicke (adult): thiamine 500 mg IV (diluted in saline, over 30 min) 2-3 times daily, or IM (at least 500 mg daily), for at least 3-5 days; then at least 300 mg daily for 1-2 weeks
- Give thiamine before glucose. Low blood glucose: give glucose now and thiamine as soon as possible
- Coagulopathy: use IV, not IM. Check and correct low magnesium
03Action All patients: thiamine, fluids, electrolytes
Start now, alongside withdrawal treatment.
- No Wernicke signs, poor nutrition: thiamine 300 mg IV or IM daily for 3-5 days, then 300 mg oral daily for several weeks
- No Wernicke signs, good diet: thiamine 100 mg oral three times daily for 3-5 days, then 100 mg daily (1-2 weeks in total)
- Check glucose, sodium, potassium, magnesium, phosphate and LFTs; replace low magnesium, potassium and phosphate
- Oral fluids (over 2 L/day); IV fluids if dehydrated or not tolerating oral fluids. Low sodium, heart failure or ascites: no fluid loading; set a fluid target on medical review; correct sodium slowly (osmotic demyelination risk)
- Multivitamin if poorly nourished
- Quiet, well-lit room; falls precautions
04Warning Before any benzodiazepine: check sedation risks
Never withhold a benzodiazepine for seizures or delirium; choose the agent and monitor closely.
- Older age, severe liver disease, respiratory failure, recent head injury, obesity: prefer oral lorazepam or oxazepam to diazepam; use lower doses
- Opioids, other sedatives, sleep apnoea or recent alcohol: higher risk of respiratory depression; hold the dose if drowsy
- Pregnancy: admit under high-risk maternity with a drugs-in-pregnancy team. Under 18: specialist advice
05Decision Delirium or hallucinations?
Reduced attention and awareness, confusion, or hallucinations.
- If Yes
06Warning Yes: withdrawal delirium (DTs) or hallucinations: emergency
Usually starts 2-3 days after the last drink. Delirium has other causes: look for them.
- Admit; close (1:1) nursing; HDU or ICU if severe or unsafe
- Look for sepsis, head injury, GI bleeding, hepatic encephalopathy, low glucose, low sodium
- Treat as Wernicke: high-dose IV thiamine (see the Wernicke step)
07Action DTs: benzodiazepine to light sedation
Target: awake but drowsy, or asleep and easy to rouse. Titrate to each patient.
- Oral diazepam 20 mg every 2 h until light sedation (lorazepam at equivalent dose if short-acting agent needed); DTs often need over 100 mg diazepam in total
- Rapid control needed: IV diazepam or IV midazolam, with airway and SpO2 monitoring
- Older age, liver failure, head injury: short-acting agent (lorazepam, midazolam) in HDU or ICU
- Antipsychotic only as an adjunct to adequate benzodiazepine, never alone (it lowers the seizure threshold)
- Not controlled by high-dose benzodiazepine: ICU; adjuncts are phenobarbital, dexmedetomidine, or propofol if ventilated
- Dexmedetomidine alone does not prevent seizures or delirium
08Action Monitoring (all patients)
Frequency depends on severity.
- CIWA-Ar every 1-2 h if over 20; at least every 4 h if over 10; every 6 h if under 10
- Delirium: CIWA-Ar is not valid; titrate to a sedation scale such as RASS (light sedation)
- Sedation, respiratory rate and SpO2 before each benzodiazepine dose
- Vital signs and neuro obs; aspiration and falls risk if sedated
- Review the score against the clinical picture; stop scoring after benzodiazepine has stopped and the score is 0 for 24 h
- Stop benzodiazepine within 1 week (rebound and dependence)
09Outcome Once withdrawal settles: plan ongoing care
Withdrawal treatment alone does not prevent relapse. Naltrexone: not with opioids or liver failure. Acamprosate: not in pregnancy or renal impairment.
- Offer relapse-prevention medicine: naltrexone or acamprosate
- Naltrexone: not with opioid use or dependence, acute hepatitis or liver failure
- Acamprosate: not in pregnancy, creatinine over 120 micromol/L or Child-Pugh C
- Continue oral thiamine (for example 100 mg daily) until long-term abstinence
- Refer to addiction medicine, counselling or mutual support; social work
If No10Decision Seizure in this episode?
Seizure now, or since the patient stopped drinking.
- If Yes
11Warning Yes: seizure. Do not assume it is from withdrawal
Investigate if first seizure, focal, 2 or more, over 48 h after the last drink, head injury, or no withdrawal signs.
- Seizure still going: treat as status epilepticus (IV benzodiazepine)
- Check glucose and sodium; CT head if head injury, anticoagulant, focal signs or first seizure
- Admit and monitor for at least 24 h
12Action After a withdrawal seizure: diazepam loading
Benzodiazepine prevents further seizures. Phenytoin and other anticonvulsants do not.
- Stable adult: diazepam 20 mg oral every 2 h until 60-80 mg in total or lightly sedated
- Concern about breathing or neurological state: lorazepam 1-2 mg oral instead
- Parenteral treatment needed (acute care): IV midazolam with airway and SpO2 monitoring
- Monitor vital signs, withdrawal score and neuro obs for 48-72 h
- Path rejoins step 08Shared downstream outcome
If No13Action No delirium or seizure: assess risk and setting
Predicts severe withdrawal and sets the place of care.
- High risk: past withdrawal seizures or delirium, or past severe withdrawal
- Heavy use of other drugs (benzodiazepines, opioids, stimulants)
- Significant medical or psychiatric illness; older age
- Time of last drink; breath or blood alcohol level
- Any high risk: inpatient care. Outpatient only if mild-moderate withdrawal expected, safe home and daily support
14Action CIWA-Ar score (trained staff)
10 items, total 0-67. Rates severity; it does not diagnose withdrawal.
- Not valid with sepsis, hepatic encephalopathy, head injury, severe pain, delirium or other drug withdrawal
- Cannot communicate or score not valid: use a fixed schedule and get specialist advice
- Beta-blockers or clonidine mask tremor, sweating and fast heart rate and can give a falsely low score
- Items 0-7 each: nausea/vomiting, tremor, sweating, anxiety, agitation, tactile, auditory and visual disturbances, headache
- Orientation and clouding of sensorium: 0-4
15Decision Choose the diazepam regimen
Use the first regimen that applies.
- Severe or high risk
16Action CIWA-Ar over 20, or past withdrawal seizure or DTs: diazepam loading
Adult. Oral diazepam. Hold the dose if drowsy.
- Diazepam 20 mg oral every 2 h until 60-80 mg in total or lightly sedated
- Check sedation and breathing before each dose
- Older age or liver disease: lorazepam instead (2 mg = diazepam 10 mg)
- Still agitated after 80 mg or 4 h: medical review; look for other causes
- Over 120 mg only after specialist review
- Then reducing doses over 3-5 days
- Path rejoins step 08Shared downstream outcome
- Comorbidity or outpatient
17Action Illness, other drug use, outpatient or no trained staff: fixed schedule
Adult. Oral diazepam, reducing over 4-5 days. Review at least daily; hold if sedated.
- Older age or liver disease: lorazepam or oxazepam at equivalent doses instead of diazepam
- Moderate-severe expected: day 1 diazepam 20 mg four times daily; day 2 10 mg four times daily; day 3 10 mg twice daily; day 4 5 mg twice daily; day 5 5 mg 12-hourly as needed
- Mild expected: day 1 diazepam 10 mg four times daily; day 2 10 mg three times daily; day 3 10 mg twice daily; day 4 5 mg twice daily; day 5 5 mg at night as needed
- Extra diazepam 5 mg 6-12 hourly as needed, by score or observation
- Outpatient: mild regimen only; daily dispensing or carer supervision; no diazepam if still drinking
- Path rejoins step 08Shared downstream outcome
- Otherwise
18Decision Otherwise: symptom-triggered diazepam by CIWA-Ar score
Only with trained staff, no past withdrawal seizures, no other drug withdrawal and no major illness.
- Under 10
19Action CIWA-Ar under 10: no diazepam dose
Repeat CIWA-Ar every 6 h.
- Low tolerance of symptoms: diazepam 5-10 mg oral as needed
- Path rejoins step 08Shared downstream outcome
- 10-20
20Action CIWA-Ar 10-20: diazepam 5-10 mg oral
Repeat CIWA-Ar at least every 4 h and dose by score.
- Diazepam 5-10 mg oral each time the score is 10-20
- Older age or liver disease: lorazepam or oxazepam instead
- Equivalent oral doses: diazepam 10 mg = lorazepam 2 mg; diazepam 5 mg = oxazepam 15-30 mg
- Path rejoins step 08Shared downstream outcome
- Over 20
21Action CIWA-Ar over 20: severe, change to loading
Adult: diazepam 20 mg oral every 2 h until 60-80 mg in total or lightly sedated.
- Older age or liver disease: lorazepam instead (2 mg = diazepam 10 mg)
- CIWA-Ar every 1-2 h
- Still agitated after 80 mg or 4 h: medical review
- Consider HDU
- Path rejoins step 08Shared downstream outcome
Guideline Source
Guidelines for the Treatment of Alcohol Problems (Australian Government, Haber & Riordan), 2021, Chapter 8 Alcohol withdrawal management
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- CIWA-Ar is not valid in delirium, sepsis, hepatic encephalopathy, head injury, other drug withdrawal, or if the patient cannot communicate: use a fixed schedule and specialist advice.
- Doses are for adults. Pregnancy, under 18, older age and liver disease need specialist input and different agents or doses.
- Symptom-triggered dosing needs trained staff and is not for patients with past withdrawal seizures or major comorbidity.
- Does not cover alcohol-related liver disease, pancreatitis or GI bleeding in detail.
Contraindicated Populations
Pregnancy: manage in hospital with high-risk maternity and a drugs-in-pregnancy teamChildren and adolescents under 18: specialist advice
Applicable Regions
AUUSEUGlobal
AU: Doses follow the Australian Guidelines for the Treatment of Alcohol Problems (2021). Diazepam is first line; chlordiazepoxide is not registered in Australia.
US: ASAM 2020 grades CIWA-Ar under 10 as mild, 10-18 as moderate and 19 or more as severe; chlordiazepoxide and lorazepam are also used.
Global: CIWA-Ar is widely used; follow local benzodiazepine availability and protocols.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Alcohol Withdrawal Syndrome Management (CIWA-Ar)?
The Alcohol Withdrawal Syndrome Management (CIWA-Ar) is a management clinical algorithm for Internal Medicine. It provides a structured decision tree to guide clinical decision-making, based on Guidelines for the Treatment of Alcohol Problems (Australian Government, Haber & Riordan), 2021, Chapter 8 Alcohol withdrawal management.
What guideline is the Alcohol Withdrawal Syndrome Management (CIWA-Ar) based on?
This algorithm is based on Guidelines for the Treatment of Alcohol Problems (Australian Government, Haber & Riordan), 2021, Chapter 8 Alcohol withdrawal management.
What are the limitations of the Alcohol Withdrawal Syndrome Management (CIWA-Ar)?
Known limitations include: CIWA-Ar is not valid in delirium, sepsis, hepatic encephalopathy, head injury, other drug withdrawal, or if the patient cannot communicate: use a fixed schedule and specialist advice.; Doses are for adults. Pregnancy, under 18, older age and liver disease need specialist input and different agents or doses.; Symptom-triggered dosing needs trained staff and is not for patients with past withdrawal seizures or major comorbidity.; Does not cover alcohol-related liver disease, pancreatitis or GI bleeding in detail.. Individual patient factors may require deviation from these recommendations.
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