Symptom-triggered therapy: Benzodiazepines are given only when the patient has symptoms of alcohol withdrawal. No symptoms, no medication. Patients are given the treatment they need, only when they need it.
Fixed schedule therapy: Benzodiazepine is given at fixed intervals even if symptoms are absent. There is a lot of evidence against this approach.
The symptom-triggered therapy is superior to fixed schedule therapy. Studies show that compared with patients treated with fixed schedule therapy patients treated with symptom-triggered therapy require “less medication (median 100 versus 425 mg) and a shorter treatment period (median 9 versus 68 hours), and had similar or better clinical outcomes.”
Note that you can use either IV or oral benzos with the symptom-triggered therapy approach. It’s often best to start with IV and then transition to oral.
Examples of the two approaches.
Approach #1: Symptom-triggered therapy (Give medication only when the patient has symptoms)
If CIWA-Ar ≥ 8, treat with benzos.
Lorazepam 2-4 mg, IV Push, Q4hrs PRN for CIWA score greater than 10. Notify MD if two consecutive CIWA scores greater than 10
Approach #2: Fixed schedule therapy (you schedule benzos)
-ChlordiazePOXIDE 25 mg by mouth three times daily.
-Lorazepam 2mg IV push q4hr prn, anxiety/agitation.