Intern report pearls – Alcohol withdrawal

We had a fabulous intern report today on alcohol withdrawal. Here are some resources/tables we posted during the talk.

Sub-types of alcohol withdrawal

Name Symptoms Onset Usual duration
Minor Withdrawal Tremulousness, mild anxiety, headache, diaphoresis, palpitations, anorexia, GI upset; Nl mental status , CIWA < 15 6-24hrs 3 days
Seizures Single or brief flurry of generalized, tonic-clonic seizures, short post-ictal period; Status epilepticus rare. 6-48 hrs 2 days
Hallucinosis Intact orientation w specific hallucinations ,typically visual > tactile > auditory, normal vital signs. 12-24 hours 1-2 days
Mod/Severe Withdrawal CIWA > 15 with nl vital signs (other than mild tachycardia) 8-24 hrs Peak @ 72h, resolve in 5-7 d
Delirium Tremens Delirium, clouding of consciousness, agitation, tachycardia, hypertension, fever, diaphoresis 48 to 96 hours; sx peak at 5 days Peak at 5 days, can have prolonged course

Adapted from

Schuckit MA. Recognition and and Management of Withdrawal Delirium (Delirium Tremens) N Eng J Med 371:22 2015 2109-2113

What goes in to a CIWA score? 

Component Most severe score
Nausea or vomiting Constant nausea w vomiting 0-7
Tremor Severe tremor w arms extended 0-7
Paroxysmal sweats Drenching sweats 0-7
anxiety panic 0-7
Tactile disturbance Continuous hallucinations 0-7
Auditory disturbance Continuous hallucinations 0-7
Visual disturbance Continuous hallucinations 0-7
headache Severe HA 0-7
agitation Pacing or thrashing 0-7
orientation A&O x 0 0-4

Adapted from

Schuckit MA. Recognition and and Management of Withdrawal Delirium (Delirium Tremens)N Eng J Med 371:22 2015 2109-2113

Medications to Support sobriety



MOA Contra-indications Evidence

(oral 50-100mg daily or IM 380mg monthly)

Opioid antagonist •Opioid use



Consensus: strong evidence of modest benefit


•NNT = 20 to prevent 1 person from returning to drinking

•NNT = 12 to prevent heavy drinking


666mg TiD

Unclear. May restore GABA/glutamate balance •Reduce dose in renal impairment

•TID dosing!

Consensus: mixed evidence of mod benefit


•NNT= 12 to achieve abstinence

•No effect on heavy drinking

Disulfuram (250-500mg daily) Aldehyde dehydrogenase inhibitor •Drug drug interactions Consensus: doesnt work in the general population. May work in highly motivated ppl (doctors, pilots)

Adapted from Edelman EJFiellin DA.In the Clinic. Alcohol Use. Ann Intern Med. 2016 Jan 5;164(1):ITC1-16.



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