Guidance

Recommendations

Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

1.1 Acute alcohol withdrawal

1.1.1 Admission to hospital

1.1.1.2

For young people under 16 years who are in acute alcohol withdrawal, offer admission to hospital for physical and psychosocial assessment, in addition to medically assisted alcohol withdrawal. [2010]

1.1.1.3

For certain vulnerable people who are in acute alcohol withdrawal (for example, those who are frail, have cognitive impairment or multiple comorbidities, lack social support, have learning difficulties or are 16 or 17 years), consider a lower threshold for admission to hospital for medically assisted alcohol withdrawal. [2010]

1.1.1.4

For people who are alcohol dependent but not admitted to hospital, offer advice to avoid a sudden reduction in alcohol intake and information about how to contact local alcohol support services. Note that a sudden reduction in alcohol intake can result in severe withdrawal in dependent drinkers. [2010]

1.1.2 Assessment and monitoring

1.1.2.1

Healthcare professionals who care for people in acute alcohol withdrawal should be skilled in the assessment and monitoring of withdrawal symptoms and signs. [2010]

1.1.2.3

People in acute alcohol withdrawal should be assessed immediately on admission to hospital by a healthcare professional skilled in the management of alcohol withdrawal. [2010]

1.1.3 Treatment for acute alcohol withdrawal

1.1.3.1

Offer pharmacotherapy to treat the symptoms of acute alcohol withdrawal as follows:

  • Consider offering a benzodiazepine or carbamazepine. Follow the MHRA safety advice on antiepileptic drugs in pregnancy.

  • Clomethiazole may be offered as an alternative to a benzodiazepine or carbamazepine. However, it should be used with caution, in inpatient settings only and according to the summary of product characteristics.

    In April 2017, this was an off-label use of some benzodiazepines (alprazolam, clobazam and lorazepam) and carbamazepine. See NICE's information on prescribing medicines. Refer to the summary of product characteristics for cautions in specific populations for all medicines for acute alcohol withdrawal. [2010, amended 2021]

1.1.3.2

People with decompensated liver disease who are being treated for acute alcohol withdrawal should be offered advice from a healthcare professional experienced in the management of patients with liver disease. [2010]

1.1.3.3

Offer information about how to contact local alcohol support services to people who are being treated for acute alcohol withdrawal. [2010]

1.1.3.4

Follow a symptom-triggered regimen for drug treatment for people in acute alcohol withdrawal who are:

  • in hospital or

  • in other settings where 24‑hour assessment and monitoring are available. [2010]

1.1.4 Management of delirium tremens

1.1.4.1

In people with delirium tremens, offer oral lorazepam as first-line treatment. If symptoms persist or oral medication is declined, offer parenteral lorazepam or haloperidol.

In April 2017, this was an off-label use of lorazepam and haloperidol. See NICE's information on prescribing medicines. Refer to the summary of product characteristics for cautions in specific populations. [2010, amended 2017]

1.1.4.2

If delirium tremens develops in a person during treatment for acute alcohol withdrawal, review their withdrawal drug regimen. [2010]

1.1.5 Management of alcohol withdrawal seizures

1.1.5.1

In people with alcohol withdrawal seizures, consider offering a quick-acting benzodiazepine (such as lorazepam) to reduce the likelihood of further seizures.

In April 2017, this was an off-label use of lorazepam. See NICE's information on prescribing medicines. Refer to the summary of product characteristics for cautions in specific populations. [2010]

1.1.5.2

If alcohol withdrawal seizures develop in a person during treatment for acute alcohol withdrawal, review their withdrawal drug regimen. [2010]

1.1.5.3

Do not offer phenytoin to treat alcohol withdrawal seizures. [2010]

1.2 Wernicke's encephalopathy

1.2.1.1

Offer thiamine to people at high risk of developing, or with suspected, Wernicke's encephalopathy. Thiamine should be given in doses toward the upper end of the 'British national formulary' range. It should be given orally or parenterally as described in recommendations 1.2.1.2 to 1.2.1.4. [2010]

1.2.1.3

Offer prophylactic parenteral thiamine followed by oral thiamine to harmful or dependent drinkers:

  • if they are malnourished or at risk of malnourishment or

  • if they have decompensated liver disease

    and in addition

  • they attend an emergency department or

  • are admitted to hospital with an acute illness or injury. [2010]

1.2.1.4

Offer parenteral thiamine to people with suspected Wernicke's encephalopathy. Maintain a high level of suspicion for the possibility of Wernicke's encephalopathy, particularly if the person is intoxicated. Parenteral treatment should be given for a minimum of 5 days, unless Wernicke's encephalopathy is excluded. Oral thiamine treatment should follow parenteral therapy. [2010]

Terms used in this guideline

Acute alcohol withdrawal

The physical and psychological symptoms that people can experience when they suddenly reduce the amount of alcohol they drink if they have previously been drinking excessively for prolonged periods of time.

Alcohol dependence

A cluster of behavioural, cognitive and physiological factors that typically include a strong desire to drink alcohol and difficulties in controlling its use. Someone who is alcohol-dependent may persist in drinking, despite harmful consequences. They will also give alcohol a higher priority than other activities and obligations. For further information, please refer to: 'Diagnostic and statistical manual of mental disorders' (DSM‑IV) (American Psychiatric Association 2000) and 'International statistical classification of diseases and related health problems – 10th revision' (ICD‑10) (World Health Organization 2007).

Coeliac axis block

Pain relief by nerve block of the coeliac plexus.

CIWA–Ar scale

The Clinical Institute Withdrawal Assessment – Alcohol, revised (CIWA–Ar) scale is a validated 10‑item assessment tool that can be used to quantify the severity of the alcohol withdrawal syndrome, and to monitor and medicate patients throughout withdrawal. See Sullivan et al. (1989) Assessment of alcohol withdrawal: the revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA–Ar). British Journal of Addiction 84:1353-1357.

Decompensated liver disease

Liver disease complicated by jaundice, ascites, variceal bleeding or hepatic encephalopathy.

Discriminant function

Maddrey's discriminant function (DF) was described to predict prognosis in alcohol-related hepatitis and identify patients suitable for treatment with steroids. It is 4.6 × [prothrombin time − control time (seconds)] + bilirubin in mg/dl. To calculate the DF using bilirubin in micromol/l divide the bilirubin value by 17.

Harmful drinking (high-risk drinking)

  • A pattern of alcohol consumption that is causing mental or physical damage (ICD‑10, DSM‑V).

  • Consumption (units per week): Drinking 35 units a week or more for women. Drinking 50 units a week or more for men.

Hazardous drinking (increasing risk drinking)

  • A pattern of alcohol consumption that increases someone's risk of harm. Some would limit this definition to the physical or mental health consequences (as in harmful use). Others would include the social consequences. The term is currently used by the World Health Organization to describe this pattern of alcohol consumption. It is not a diagnostic term.

  • Consumption (units per week): Drinking more than 14 units a week, but less than 35 units a week for women. Drinking more than 14 units a week, but less than 50 units for men.

Malnourishment

A state of nutrition in which a deficiency of energy, protein and/or other nutrients causes measurable adverse effects on tissue/body form, composition, function or clinical outcome.

Medically assisted alcohol withdrawal

The deliberate withdrawal from alcohol by a dependent drinker under the supervision of medical staff. Prescribed medication may be needed to relieve the symptoms. It can be carried out at home, in the community or in a hospital or other inpatient facility.

Splanchnicectomy

Surgical division of the splanchnic nerves and coeliac ganglion.

Symptom-triggered regimen

Treatment tailored to the person's individual needs, which are determined by the severity of withdrawal signs and symptoms. The patient is regularly assessed and monitored, either using clinical experience and questioning alone or with the help of a designated questionnaire such as the CIWA–Ar. Drug treatment is provided if the patient needs it and treatment is withheld if there are no symptoms of withdrawal.