Choosing agent and dose for supervised alcohol withdrawal in the ambulatory setting*

CIWA-Ar: Clinical Institute Withdrawal Assessment for Alcohol, Revised.

* This algorithm assumes the individual is appropriate for treatment in the ambulatory setting. Refer to other UpToDate content for treatment-setting considerations.

¶ We prescribe daily thiamine (100 mg) and folic acid (400 mcg to 1 mg) to all individuals being treated for alcohol withdrawal.

Δ We adjust doses of gabapentin in individuals with chronic kidney disease (refer to Lexicomp for dose adjustments). For individuals with adverse reactions to or history of poor response to gabapentin, carbamazepine is our next choice. Long-acting benzodiazepines are an option if benzodiazepines are preferred.

◊ For individuals taking gabapentin for another indication, our preference is to use a benzodiazepine taper.

§ We provide five doses of symptom-triggered medication along with the fixed doses of medication. We instruct the individual to take a symptom-triggered dose for worsening or emergence of symptoms of withdrawal. We allow one symptom-triggered medication dose every 24 hours in addition to the fixed doses. If more than one dose is needed, we refer for treatment in a setting with a higher level of care (ie, inpatient). We provide five doses for a four-day taper as, in some cases, residual symptoms (eg, anxiety, tremulousness) warrant extending the taper by one day.

¥ A long-acting benzodiazepine taper is used for fixed-dose taper the ambulatory setting. Choice of long-acting benzodiazepine (diazepam or chlordiazepoxide) is based on clinician comfort and familiarity as well as patient preference.