View source for Alcohol withdrawal: Inpatient management

==Management==
''Start aggressive [[Benzodiazepines|Benodiazepine]] therapy at CIWA score of 8. Consider ICU admission with score >20''

===[[Benzodiazepines]]===
*[[Diazepam]] (Valium) 5-10mg IV (depending on severity)
**May repeat q5-10min for severe withdrawal (double dose until desired effect achieved)
*[[Lorazepam]] (Ativan) 1-4mg IV (depending on severity)
**May repeat q15-20min for severe withdrawal (titrated to effect)
**Rarely causes hepatitis, as opposed to diazepam which may cause a cholestatic hepatitis<ref>National Institute of Diabetes and Digestive and Kidney Diseases. Lorazepam Drug Record. http://livertox.nih.gov/Lorazepam.htm</ref>

====Special Situations====
*The propylene glycol diluent in lorazepam, phenobarbital and diazepam, may induce a hyperosmolar anion gap metabolic acidosis if given as a drip in high doses ≥ 48hrs.<ref>Arroliga AC, Shehab N, McCarthy K, Gonzales JP. Relationship of continuous infusion lorazepam to serum propylene glycol concentration in critically ill adults*. Critical Care Medicine. 2004;32(8):1709–1714. doi:10.1097/01.CCM.0000134831.40466.39.</ref>  Consider alternatives such as propofol or dexmedetomidine if patients need long term sedation for [[Delirum Tremens]]

===Alpha-2 agonists ([[Dexmedetomidine]])===
*Decrease severity of sxs, but only supplemental to GABA-ergic first-lines
* Dexmedetomidine drip, start 0.2 mcg/kg/min, likely needing no more than 0.7 mcg/kg/min

===[[Barbituates]] ([[Phenobarbital]])===
*Used when refractory to [[benzodiazepines]]
* [[Phenobarbital]] 130-260 mg IV q 15-20 minutes

===[[Ketamine]]===
*May have some use in refractory cases
*Blocks the NMDA receptor which is excited an unregulated. <ref>Wong, A et al. Evaluation of adjunctive ketamine to benzodiazepines for management of alcohol withdrawal syndrome. Ann Pharmacother. 2015 Jan;49(1):14-9. PMID: 25325907</ref>

===Nutritional supplementation===
*Banana bag
**Thiamine 100mg IV
**Folate 1mg IV (cheaper PO)
**MVI 1 tab IV (cheaper PO)
**[[Magnesium sulfate]] 2mg IV
**Normal saline as needed for hydration

==See Also==
*[[Beer Potomania Syndrome]]
*[[Alcohol (ETOH) Intoxication]]
*[[Alcoholic ketoacidosis]]
*[[Alcohol withdrawal]]
*[[Alcohol withdrawal: Inpatient management]]
*[[Alcohol withdrawal: Outpatient management]]
*[[Alcohol withdrawal seizures]]
*[[Altered mental status]]
*[[Delerium tremens]]
*[[EBQ:Outpatient use of benzodiazepines for the treatment of acute alcohol withdrawal]]
*[[Sedative/Hypnotic]]
*[[Wernicke-Korsakoff Syndrome]]

==External Links==

==References==
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