Table 2-11Summary of included studies

StudyStudy type and numberPatient population and settingInterventionComparison
Pletcher 200552Retrospective case series, N=500Patients with alcohol-related discharge diagnosis (ICD- 9)

Setting: General hospital
Post-protocol, N=202

CIWA monitoring fixed dose scheduling for at risk or symptomatic patients with CIWA monitoring to allow for extra doses as-needed.

Education campaign

Standard order form
Pre-protocol, N=188

Fixed-schedule dosing without the use of standard monitoring
Repper- DeLisi 200850Retrospective case series 3, N=80Patients with alcohol withdrawal

alcohol consumption within two weeks of admission and/or withdrawal or treatment for alcohol withdrawal during the index admission

Setting: medical and surgical patients admitted to a general hospital
Post-pathway, N=40

Pathway developed to: Increase recognition of those at risk of withdrawal and to treat patients before they became symptomatic. Also, to facilitate aggressive treatment of alcohol withdrawal

Assessment consisted of: CAGE, vital signs, alcohol history, withdrawal signs, delirium, risk factors.

Treatment: fixed dose benzodiazepines

Training and education program
Pre-pathway, N=40

Benzodiazepines at the discretion of staff, such as without a protocol
Hecksel 200854Retrospective case series 3, N=124 episodesPatients who received symptom- triggered therapy according to the CIWA-Ar protocol

Setting: Medical and surgical patients admitted to a general hospital
Appropriate symptom- triggered therapyInappropriate symptom-triggered therapy
DeCarolis 200755Retrospective case series 3

N=40
Patients admitted to a medical intensive care unit with a primary diagnosis of severe alcohol withdrawalProtocol-treated patients

N=24 (21 patients)

Minnesota Detoxification Scale (MINDS) to monitor symptoms.

Treatment: Lorazepam administered as intermittent intravenous doses, progressing to a continuous intravenous infusion according to the MINDS score

Assessments performed every 15 minutes to 2 hours depending on MINDS scoreb
Non-protocol patients

N=16 (15 patients)

Patients treated according to physician preference; the standard local practice was administration of a continuous infusion of midazolam without a protocol
Stanley 200751Before and after retrospective case series 3Patients at risk of alcohol withdrawal admitted to the surgery or internal medicine servicesGuideline managed patients, N=106

The guideline comprised of: Symptom- triggered dosing schedule, guideline on how to manage a seizure or delirium and patients with specified comorbid conditions. Monitor using the Alcohol Withdrawal Scale type indicator every two to four hours according to score
Non-guideline managed patients, N=82

Prior to the guideline benzodiazepines were given around the clock and/or as needed and these vitamin supplements were commonly prescribed for patients with suspected or known alcohol abuse
Foy 199749Prospective case series N=539Patients with alcohol withdrawal

Inclusion criteria (one or more of the following): 100g alcohol daily or more; admission with an alcohol- related diagnosis; previous documented alcohol withdrawal and still drinking; a blood alcohol level of 0.2% without impairment of consciousness, and who had an Alcohol Withdrawal Scale (AWS) ≥ 10
Alcohol Withdrawal Scale (AWS) – modification of the CIWA-A

Loading dose diazepam 20 mg if:
Two scores of 15 or more or one of 20 then consider treatment but the decision to treat, dose and technique was at the discretion of the treating team

Timing of assessment If AWS ≥10 assess every two hours, if ≥15 then hourly
Whether a delay in assessment was associated with seizures, hallucinations and delirium
Wetterling 199714Prospective case series 3, N=387Patients with long-standing alcohol dependence (DSM-IV) admitted for detoxification.

Setting: psychiatric emergency ward
Symptom-based protocol, N=256

Alcohol Withdrawal Scale (AWS) derived from the CIWA-Ar.

AWS administered every 2 hours

Treatment protocol: Mild AWS – no medication Moderate AWS – carbamazepine up to 900mg/day Severe AWS – clomethiazole.
Non-protocol group (validation phase), N=131

Patients were treated without reference to a rating scale (no further details reported).
Morgan 199653Retrospective before and after time series/case series 3, N=197Patients needing hospitalization to treat uncomplicated alcohol withdrawal syndrome.

Setting: psychiatric unit
Post-pathway, N=56

Pathway for uncomplicated alcohol withdrawal incorporating the use of the CIWA-Ar

Move towards symptom- triggered dosing but clinicians made decisions independently benzodiazepine prescribing

One year after pathway implementation

N=75

Pathway included a protocol for benzodiazepine dosing according to a symptom- triggered CIWA-Ar based schedule
Pre-pathway, N=66

No standard assessment scale. Implied that fixed- dosing scheduling used but not explicitly stated.
Jaeger 200132Retrospective case series 3

N=216 admissions
Patient with a discharge diagnoses of alcoholism, delirium tremens, alcohol withdrawal or alcohol withdrawal seizures. Patients who received thiamine and benzodiazepines simultaneously.

Setting: Patients on general medical wards
Symptom- triggered (Post implementation), N=84

CIWA-Ar administered every 1 to 2 hours

CIWA-Ar ≥ 10: chlordiazepoxide 50 to 100 mg starting dose and then repeated until ‘CIWA-Ar score began to decline’
Usual care (Pre- implementation), N=132

‘Empirical’ dosage usually on a tapering fixed-dose or with as- needed doses at the discretion of medical staff
Reoux 200033Retrospective case analysis 3

N=40
Patients with discharge codes for alcohol withdrawal, delirium tremens, drug withdrawal or alcohol hallucinosis

Setting: Alcohol unit, medication ward, inpatient psychiatry unit
Symptom triggered dosing (CIWA-Ar), N=26

CIWA-Ar ≥10 30mg oxazepam or 50 mg chloridazepoxide

CIWA-Ar administered hourly and continued to receive medication until the score dropped below 10.
Non-protocol based detoxification, N=14

Detoxification occurred in a general medication ward (N=6) or inpatient psychiatry unit (N=8)

Protocol:
Medication ordered on a scheduled plus PRN (5/8 [62%]) or PRN only (3/8 [38%])

From: 2, Acute Alcohol Withdrawal

Cover of Alcohol Use Disorders
Alcohol Use Disorders: Diagnosis and Clinical Management of Alcohol-Related Physical Complications [Internet].
NICE Clinical Guidelines, No. 100.
National Clinical Guideline Centre (UK).
Copyright © 2010, National Clinical Guidelines Centre.

Apart from any fair dealing for the purposes of research or private study, criticism or review, as permitted under the Copyright, Designs and Patents Act, 1988, no part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of the publisher or, in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency in the UK. Enquiries concerning reproduction outside the terms stated here should be sent to the publisher at the UK address printed on this page.

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.