From HM17: a practical guide to managing alcohol withdrawal syndrome

Alcohol remains one of the most common substances bringing Australians into acute hospital care, with the Australian Institute of Health and Welfare consistently ranking alcohol-related harm among the top five avoidable causes of admission. From inner-city Sydney emergency departments to remote Western Australian clinics, hospitalists are routinely the first clinicians to recognise and treat withdrawal. The Society of Hospital Medicine's flagship meeting in Las Vegas in May 2017 devoted considerable session time to a pragmatic, ward-based approach to this everyday presentation, and the take-home messages translate well to Australian practice.

Several HM17 presenters distilled the conference pearls into protocols that favour symptom-triggered dosing over rigid fixed schedules. These align closely with the National Health and Medical Research Council (NHMRC) Australian Guidelines to Reduce Health Risks from Drinking Alcohol, which emphasise screening, brief intervention, and escalation pathways for risky drinkers. The same bedside-first philosophy underpins hospital policies at institutions such as Melbourne's Alfred Hospital and Sydney's Royal Prince Alfred, where CIWA-Ar-driven protocols are now standard.

This summary walks through the practical steps an Australian hospitalist can apply within the first 24 to 72 hours of care, from initial CIWA-Ar scoring through to benzodiazepine selection, thiamine replacement, escalation triggers, and safe discharge. It assumes the clinician works within the constraints of the Pharmaceutical Benefits Scheme, state-based liquor and drug legislation, and the realities of a mixed metropolitan-regional patient population.

The goal is to keep patients safe, calm, and out of the intensive care unit whenever possible, while ensuring those who do need a higher level of care reach it quickly. The discussion draws on presentations from the official HM17 portal, where session recordings and slide decks remain accessible to delegates and subscribers.

CIWA-Ar in the Australian context

The Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar) scale is the workhorse of alcohol withdrawal management in most major Australian hospitals. A score of 8 to 15 indicates mild-to-moderate withdrawal, while anything above 15 typically prompts more aggressive treatment. The instrument is short, repeatable every 15 to 30 minutes during active withdrawal, and maps neatly to a symptom-triggered benzodiazepine protocol. Nurses in wards at the Royal Adelaide Hospital, for example, can administer diazepam 10 to 20 mg orally according to a prespecified sliding scale without a fresh medical order each time, provided the patient is on an approved withdrawal management order.

A practical point raised repeatedly at HM17 was that scoring must be paired with clinical judgement. A patient with a CIWA-Ar of 6 who is also febrile and tachycardic warrants closer attention than the number alone would suggest. Conversely, a patient scoring 12 who is well, hydrated, and eating breakfast can often be managed with oral diazepam and review. The conference speakers encouraged clinicians to document the rationale whenever they deviate from the protocol, an approach that mirrors the open-disclosure expectations of the Australian Commission on Safety and Quality in Health Care.

Pulse oximetry, blood pressure, and temperature should be charted at the same intervals as the CIWA-Ar. Alcohol withdrawal is not a static condition; the trajectory over four to six hours matters more than any single reading. For patients in regional Queensland or northern Tasmania, where transfer times to a tertiary centre can exceed four hours by road, early recognition of deterioration is critical, and the local GP or retrieval service should be looped in well before a crisis develops.

Benzodiazepine selection and PBS logistics

Diazepam remains the first-line benzodiazepine for alcohol withdrawal in Australia, largely because of its long half-life, which provides a smoother plasma profile than shorter-acting agents. It is PBS-listed for this indication, and oral diazepam 5 mg and 10 mg tablets are inexpensive and widely available in hospital imprests. For patients who cannot swallow, intravenous diazepam via a large peripheral cannula is appropriate, although intramuscular absorption is erratic and should be avoided. Lorazepam, given sublingually or intravenously, is reserved for patients with significant hepatic impairment, such as those with Child-Pugh B or C cirrhosis, where the oxidative metabolism of diazepam is unreliable.

Symptom-triggered dosing was a recurring theme across the HM17 sessions. A typical Australian protocol uses diazepam 10 mg orally every hour when CIWA-Ar is 8 to 14, and 20 mg orally every hour when the score is 15 or higher, with a ceiling of 60 to 80 mg in the first 24 hours. Some hospitals, including several in Western Australia, have adopted front-loaded regimens where 20 mg is given every two hours for the first three doses regardless of score, aiming to saturate receptors and prevent the rebound that drives delirium tremens.

Clinicians should be aware of interactions with other sedatives commonly prescribed in Australian hospitals, particularly opioids and antipsychotics such as olanzapine or haloperidol. Where polypharmacy is unavoidable, a lower benzodiazepine ceiling and more frequent observation are prudent. Patients over 65, a growing cohort on Australian medical wards, are at particular risk of falls and over-sedation, and non-pharmacological measures such as a low-stimulus environment and dim lighting should be prioritised during the acute phase.

Thiamine replacement and Wernicke's prophylaxis

Wernicke's encephalopathy remains under-recognised in Australian hospitals, and the HM17 faculty dedicated a full session to closing the gap. The classic triad of confusion, ataxia, and ophthalmoplegia is present in only a minority of cases, and the conference speakers urged clinicians to treat on suspicion rather than wait for the full clinical picture. Australian guidelines, including those used at the Royal Melbourne Hospital, recommend parenteral thiamine before any carbohydrate load, based on decades of evidence that glucose without thiamine can precipitate or worsen Wernicke's in at-risk patients.

A practical regimen is thiamine 200 mg intravenously or intramuscularly, three times daily for three to five days, followed by oral thiamine 100 mg daily for at least a month. The intravenous route is preferred when malabsorption is suspected, including in patients with frequent vomiting, pancreatitis, or a history of bariatric surgery. Thiamine is PBS-subsidised and must never be given as a brief bolus; slow infusion over 15 to 30 minutes reduces the small but real risk of anaphylaxis reported in the literature.

For Aboriginal and Torres Strait Islander patients, who carry a disproportionately high burden of alcohol-related harm in many regions, clinicians should consider additional barriers to ongoing oral thiamine supply after discharge, including remoteness, cost, and access to culturally safe primary care. Connecting patients with Aboriginal Medical Services before discharge can make a meaningful difference. In remote areas serviced by the Royal Flying Doctor Service, primary care clinics often hold a small stock of intramuscular thiamine for emergencies, and the hospital team should communicate the discharge plan directly with the receiving clinic.

Severe withdrawal, delirium tremens and ICU avoidance

Delirium tremens typically develops 48 to 96 hours after the last drink and carries a mortality of up to 15 per cent if untreated. The HM17 speakers stressed that most cases can be prevented by adequate front-loading of benzodiazepines in the first 24 hours, and that escalation should be considered on physiological trajectory as much as CIWA-Ar score. A rising heart rate, increasing temperature, and deepening confusion despite appropriate diazepam doses are red flags that warrant senior review, a MET call, or early discussion with intensive care.

For patients who do require higher-level care, intravenous midazolam or propofol in a monitored setting may be necessary. Australian ICUs are familiar with this presentation, particularly during weekends and public holidays, and the decision to transfer should not be delayed. In rural and regional hospitals without on-site ICU cover, retrieval via the local critical care transfer service is the usual pathway, and early activation is preferable to late. Lessons from the same conference on avoiding unnecessary ICU admission, summarised in a companion HM17 COPD summary, apply equally here: clear escalation criteria, good communication, and proactive symptom control reduce crash calls.

Adjunctive agents such as haloperidol should be reserved for refractory agitation rather than used as first-line therapy, because they lower the seizure threshold and prolong the QT interval. Patients with a history of withdrawal seizures, those over 65, and those with significant comorbidities such as pneumonia, alcoholic hepatitis, or gastrointestinal bleeding are at higher risk of complicated withdrawal and warrant a lower threshold for transfer. Daily multidisciplinary review with pharmacy, nursing, and addiction medicine input, where available, helps catch drift before it becomes a crisis.

Discharge planning beyond the hospital walls

Discharge is where Australian hospitalists can have the biggest long-term impact. A patient leaving the ward on diazepam for five to seven days, with a clear tapering plan, is far better protected against early relapse and re-attendance than one sent home with an open script and no follow-up. Addiction medicine consultation, where the hospital has a service, should be offered routinely rather than only when requested by the patient, as many who would benefit are reluctant to ask.

Linkage with community services is equally important. DrinkWise Australia, the Australian Drug Information Network, and state-based alcohol and drug hotlines are all accessible from a hospital phone and can be introduced before discharge. For patients in rural South Australia or outback New South Wales, telehealth follow-up with an addiction specialist based in Adelaide or Sydney is now a realistic option, supported by Medicare item numbers for specialist video consultations. A printed, plain-language summary of the withdrawal episode, the medications used, and the warning signs of recurrence should go home with the patient, with a copy sent to their GP.

Families and carers, with the patient's consent, should be included in the conversation. They are often the first to notice the early signs of relapse and can support the medication plan if they understand it. Naltrexone, acamprosate, and disulfiram are all PBS-listed for relapse prevention and can be discussed with the GP as part of a shared care arrangement.

Print and file a one-page CIWA-Ar plus thiamine protocol in the bedside folder of every medical ward, and review it at the next departmental meeting so that the whole team is using the same thresholds and doses.