Patient handout

Acute Alcohol Withdrawal — inpatient management

PRODUCTION

1. Your condition

This handout is for acute alcohol withdrawal — inpatient management. Your care team identified this based on: tremor, diaphoresis, anxiety, autonomic hyperactivity after recent cessation/reduction of alcohol (dsm-5-tr 2022; asam 2020).

Other reasons your team may use this plan: witnessed or reported generalized tonic-clonic seizure within 24–48 h of alcohol cessation (mayo-smith jama 1997); delirium tremens — clouded sensorium + hallucinations + autonomic storm + disorientation (mayo-smith jama 1997); heavy chronic alcohol use (>5 standard drinks/d men or >3/d women; audit-c high) with recent cessation/reduction (asam 2020).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
thiamine	500 mg IV q8h × 3 days, then 100 mg PO daily	IV → PO	q8h × 3 days then daily	Royal College CR-185 / Cook 1998 — empiric high-dose IV thiamine for Wernicke prophylaxis; oral thiamine is poorly absorbed in alcohol misuse + malnutrition; rare anaphylaxis with IV — have epinephrine available; CRITICAL: give BEFORE any dextrose/glucose to avoid precipitating Wernicke
folic_acid	1 mg PO/IV daily	PO/IV	daily	Folate deficiency common in chronic alcohol use — corrects macrocytic anemia (NICE 2010)
multivitamin	1 tablet PO daily	PO	daily	Chronic alcohol use causes multiple micronutrient deficiencies (NICE 2010)
magnesium_sulfate	2–4 g IV over 2–4 h if Mg <1.6; oral magnesium oxide 200–400 mg BID if mild	IV/PO	per repletion	Hypomagnesemia common and refractory hypokalemia/seizures depend on it (ASAM 2020)
potassium_chloride	40–80 mEq PO/IV per 0.1 mmol/L deficit	PO/IV	per repletion	Hypokalemia is common; replete Mg simultaneously (ASAM 2020)
phosphorus_repletion	Sodium or potassium phosphate 15–30 mmol IV over 4–6 h if Phos <1.5; PO Neutra-Phos if mild	IV/PO	per repletion	Hypophosphatemia common; replete to prevent refeeding-syndrome physiology on glucose load (ASAM 2020)

Plan: CIWA-Ar symptom-triggered benzodiazepine protocol + Wernicke prophylaxis + BZD-refractory adjuncts + AUD MAT bridge

3. When to call your provider

Contact your care team if any of the following happen:

Relapse with new withdrawal symptoms (CIWA-Ar rising) → urgent re-evaluation; admit if CIWA ≥ 10 or kindling history (ASAM 2020)
PHQ-9 ≥ 15 OR C-SSRS active SI OR new SI history → urgent mental-health referral; routes to psych.suicidality.ed.core.v1 (ASAM 2020)
New seizure post-discharge → ED for workup + neurology referral; reassess antiseizure medication taper (Mayo-Smith JAMA 1997)
LFTs > 5× ULN → discontinue naltrexone (or do not start) + hepatology referral (ASAM 2020)
Disulfiram-ethanol reaction (flushing + headache + nausea + tachycardia + hypotension) → ED if hemodynamic compromise (ASAM 2020)
Wernicke features (any) → ED for IV thiamine + neurology (Cook 1998 NEEDS_SOURCE_REVIEW)
Housing instability / loss of supports / IPV → social-work referral + sober-living / IOP / PHP escalation (ASAM 2020)
New cardiovascular event in patient on disulfiram → discontinue disulfiram + cardiology (ASAM 2020)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

CIWA-Ar ≥20 — severe withdrawal
Witnessed or reported generalized tonic-clonic seizure within 24–48 h of alcohol cessation(life-threatening)
Delirium tremens — clouded sensorium + autonomic storm + hallucinations + disorientation, 48–96 h after cessation(life-threatening)
Withdrawal refractory to escalating BZD doses (>40 mg lorazepam equiv. in 4 h without effect)(life-threatening)
HR >120 OR T >38.5 OR SBP >180 in alcohol withdrawal patient
Ophthalmoplegia (nystagmus, lateral rectus palsy) + ataxia + confusion — Wernicke encephalopathy(life-threatening)
Established delirium tremens with autonomic instability + clouded sensorium + visual hallucinations + disorientation, typically 48-96 h post-cessation; PAWSS ≥ 4 at admission predicts; mortality 5-15% untreated (Mayo-Smith JAMA 1997 PMID 9244334; Maldonado PAWSS 2014 NEEDS_SOURCE_REVIEW)(life-threatening)
First-episode uncomplicated generalized tonic-clonic seizure within 12-48 h of alcohol cessation; benzodiazepine load + observe for status (Mayo-Smith JAMA 1997 PMID 9244334)
Prior history of delirium tremens OR prior alcohol-withdrawal seizure — strongest predictor of current-admission complication (kindling phenomenon: each subsequent withdrawal more severe due to GABA-A receptor down-regulation + NMDA receptor up-regulation cycling)
Any of the Wernicke triad features (confusion + ophthalmoplegia + ataxia) present — even incomplete-triad presentations (e.g., isolated confusion + ataxia or isolated confusion + nystagmus); LOW threshold for treatment (Cook 1998 / Royal College CR-185; EFNS 2010)

5. Follow-up

Outpatient addiction medicine within 1 week; AUD MAT (naltrexone, acamprosate, disulfiram, gabapentin off-label) (ASAM 2020); counseling; mutual-help (AA, SMART, LifeRing); thiamine continued PO; nutritional supplementation; primary care follow-up for liver, BP, cardiac

6. Sources

Guideline: ASAM 2020 Alcohol Withdrawal Management + Sullivan CIWA-Ar 1989 + Mayo-Smith JAMA 1997 benzodiazepine guideline + Rosenson 2013 phenobarbital ED RCT + Maldonado PAWSS 2014