Experience With an Adult Alcohol Withdrawal Syndrome Practice Guideline in Internal Medicine Patients

Karen M. Stanley, MS; Cathy L. Worrall, PharmD, FAPhA; Shayna L. Lunsford, MS; Kit N. Simpson, Dr.PH; Justin G. Miller, MD; Anne P. Spencer, PharmD


Pharmacotherapy. 2005;25(8):1073-1083. 

In This Article

Abstract and Introduction

Study Objective: To standardize treatment of alcohol withdrawal syndrome (AWS) in internal medicine patients using an adult AWS practice guideline with a symptom-triggered management approach.
Design: Prospective interventional (pilot group) and retrospective (control group).
Setting: University teaching hospital.
Patients: Thirty-two internal medicine patients identified as being at risk for AWS and treated according to the AWS practice guideline who were compared with 49 internal medicine patients managed with nonstandardized approaches.
Intervention: Patients in the pilot group were assessed using the AWS type indicator. They received lorazepam, clonidine, or haloperidol, based on AWS type indicator assessment and adult AWS practice guideline criteria.
Measurements and Main Results: Data collected and analyzed were drugs administered to control AWS symptoms, use of sitters and physical restraints, length of hospital stay, and discharge from hospital receiving tapered drug therapy. Pilot patients received 46.6% less benzodiazepine (p=0.001), 20% more clonidine (p=0.01), and 18.2% more haloperidol (p=0.002) than control patients. No drug therapy was required in 19% of pilot patients compared with 2% of controls (p=0.01). Significantly more control (71.4%) than pilot patients (18.8%) were discharged with tapered benzodiazepine therapy (p≤0.01). No significant differences were found between groups for sitters, restraints, or hospital length of stay.
Conclusion: This pilot project suggests that internal medicine patients at risk for AWS can be managed with a standardized, symptom-triggered approach using decreased amounts of benzodiazepine in combination with adjunctive agents to treat adrenergic hyperactivity and delirium. Further data are necessary to determine the impact of the practice guideline on patient outcome measurements.

Concerns about the frequent occurrence of alcohol withdrawal syndrome (AWS) in patients treated at our university teaching hospital prompted the formation of a performance improvement team to examine reports in the literature regarding evidence-based practice[1] and make recommendations to improve patient management and outcomes. A comprehensive description of the original project developed and implemented by the performance improvement team was published previously.[2] Results of that project, which involved trauma, orthopedic, and general surgery patients, illustrated the effectiveness of a symptom-triggered approach[3,4] for treatment of AWS.

The AWS typology[5] method of treatment postulates that AWS is a heterogeneous syndrome that has been misunderstood as a single condition, previously classified from mild to severe. This methodology suggests that AWS consists of three distinct symptom clusters, each with its own physiologic basis and preferred treatment agents. The AWS type indicator is used to assess patients identified as being at risk for AWS (Figure 1). This instrument categorizes AWS into three distinct symptom clusters: type A (central nervous system excitation), type B (adrenergic hyperactivity) and type C (delirium). Type A symptoms are treated with the benzodiazepine lorazepam. Type B symptoms not adequately controlled by lorazepam are treated with the central α-adrenergic agonist clonidine. Type C symptoms and severe agitation[6] are treated with the neuroleptic haloperidol.

Alcohol withdrawal assessment instrument. (Adapted from reference [5].)

The adult AWS practice guideline was originally developed for use with specific surgical populations at our institution. It was revised for internal medicine patients based on feedback from previous users of the guideline and the internal medicine attending physicians. Modifications involved changing the frequency of assessment using the AWS type indicator from every hour to every 2 hours, and changing the initial order for lorazepam from 2 mg every hour as needed to 1-2 mg every hour as needed. The revised practice guideline was reviewed and approved for implementation by the institutional review board.

The purpose of this project was to assess the AWS typology method of treatment used for internal medicine patients. We hypothesized that a standardized symptom-triggered approach to managing AWS in these patients would decrease the use of benzodiazepine, increase the use of adjunctive drugs to manage adrenergic hyper-activity and delirium, decrease the need for sitters and physical restraints, and reduce hospital length of stay (LOS) without increasing adverse events.


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