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MODULE 36: COMMON ORDER SETS & PROTOCOL CONSULTS: A PHARMACIST’S GUIDE
The Alcohol Withdrawal (CIWA) Protocol
A guide to symptom-triggered therapy for alcohol withdrawal. We will cover the CIWA scoring tool, the role of benzodiazepines, adjunctive therapies, and managing refractory delirium tremens.
SECTION 36.5
The Alcohol Withdrawal (CIWA) Protocol
From Benzodiazepine Expert to Delirium Navigator: The Pharmacist’s Role in Managing a Neurological Storm.
36.5.1 The “Why”: A Preventable Catastrophe
In your retail practice, you are a master of benzodiazepine tapering and counseling. You’ve spent years helping patients safely discontinue alprazolam, clonazepam, and lorazepam, meticulously guiding them through dose reductions to avoid the misery of withdrawal. You understand the profound neuroadaptation that occurs with chronic GABA-A receptor agonism. Now, imagine that process, but compressed from months into a matter of hours, and amplified to a life-threatening intensity. That is acute alcohol withdrawal syndrome (AWS).
Chronic heavy alcohol use saturates and upregulates the brain’s GABA-A receptors, the primary inhibitory system. When alcohol is abruptly withdrawn upon hospital admission, this braking system is suddenly removed. The brain’s excitatory systems, primarily driven by glutamate, are now unopposed, creating a neurological firestorm. This manifests as a predictable cascade of symptoms, starting with tremors and anxiety, and progressing in severe cases to seizures, hallucinations, and a state of profound confusion and autonomic hyperactivity known as Delirium Tremens (DTs). Severe, untreated alcohol withdrawal has a mortality rate as high as 20%. It is one of the most dangerous, and yet most preventable, conditions you will manage in the hospital.
The “Alcohol Withdrawal Protocol” or “CIWA Order Set” is the hospital’s primary tool for preventing this catastrophe. It is a standardized, nurse-driven protocol that allows for the administration of benzodiazepines based on the severity of a patient’s objective withdrawal symptoms. Your role is multifaceted. You are the verifier, ensuring the initial orders are safe and appropriate. You are the consultant, providing recommendations for choosing the right agent and dose. And you are the safety net, monitoring for signs of undertreatment (progression to DTs) or overtreatment (oversedation) and intervening when the protocol is no longer sufficient. This section will give you the mastery to navigate this neurological storm with confidence.
Retail Pharmacist Analogy: The High-Speed Benzodiazepine Taper
Imagine a patient comes to your pharmacy in a panic. They’ve been taking alprazolam 2mg four times a day for ten years, prescribed by a doctor who just retired. They are down to their last two tablets and cannot find a new doctor to see them for another week. They are already feeling shaky and anxious. You know that abruptly stopping this dose is a recipe for a seizure.
You are now in the role of an emergency withdrawal manager.
- The Assessment: You don’t just give them a few tablets. You assess the severity. You ask about their symptoms (the CIWA Score). You recognize the urgency.
- The Intervention: You know that you need to replace their short-acting alprazolam with a long-acting benzodiazepine to provide a smoother “taper.” You call the local emergency room, explain the situation, and get a verbal order for a 7-day supply of diazepam (Valium) (the Benzodiazepine Therapy). You’ve chosen the right tool for the job.
- The Supportive Care: You also counsel the patient on the importance of hydration and nutrition, and you give them information for a local addiction support group. You might even suggest a B-complex vitamin. This is your Adjunctive Therapy (Thiamine, Folate).
- The Safety Net: You tell them, “If you start to feel extremely confused, see things that aren’t there, or have a seizure, you must call 911 immediately.” This is your plan for Refractory Symptoms.
Managing a CIWA protocol in the hospital is the same intellectual process. You are assessing the severity of withdrawal and applying a controlled, tapering dose of a cross-tolerant medication (benzodiazepines) to safely guide the patient’s nervous system back to a stable baseline.
36.5.2 Deconstructing the CIWA-Ar Scale: Quantifying the Storm
The foundation of modern alcohol withdrawal management is the Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar) scale. This is a 10-item, nurse-administered scoring tool that transforms a subjective constellation of symptoms into an objective, actionable number. This score is what drives the entire treatment algorithm. You must understand what it measures and what the scores mean.
Masterclass Visual Guide: The 10 Domains of the CIWA-Ar Scale
Nausea/Vomiting
Tremor
Anxiety
Agitation
Paroxysmal Sweats
Clouding of Sensorium
Visual Disturbances
Auditory Disturbances
Headache
Tactile Disturbances
Each of these 10 items is scored on a scale, typically from 0 (not present) to 7 (severe). The maximum possible score is 67. The nurse will assess the patient, calculate a total score, and that score will correspond to a specific action on the order set.
Translating Scores into Action: The Treatment Thresholds
Every CIWA protocol is built around a set of scoring thresholds. While the exact numbers may vary slightly between institutions, the principle is universal.
| CIWA-Ar Score | Interpretation | Typical Action on the Order Set |
|---|---|---|
| < 8-10 | Mild Withdrawal | No medication needed at this time. Continue to monitor every 4-6 hours. |
| 10 – 18 | Moderate Withdrawal | TREAT. Administer one dose of the ordered benzodiazepine (e.g., Lorazepam 2 mg). Re-assess CIWA in 1 hour. |
| > 18-20 | Severe Withdrawal | TREAT AGGRESSIVELY. Administer a higher dose of the ordered benzodiazepine (e.g., Lorazepam 4 mg). Re-assess CIWA in 1 hour. Notify provider. |
36.5.3 The Pharmacist’s Playbook: Verifying the CIWA Order Set
When the CIWA protocol is initiated, your job is to verify the initial orders and ensure the chosen therapy is safe and appropriate. This involves a rapid but systematic review.
Masterclass Table: The Benzodiazepine Selection Guide
| Benzodiazepine | Key Features | Ideal Patient Population | Pharmacist “Gotcha” |
|---|---|---|---|
| Diazepam (Valium) | Very long half-life, rapid onset. Self-tapering effect due to long-acting metabolites. | Younger patients with good liver function. The long half-life provides a smooth, auto-tapering course. | AVOID in the elderly and in patients with severe liver disease (cirrhosis). The long-acting metabolites can accumulate to toxic levels, causing profound and prolonged oversedation. |
| Lorazepam (Ativan) | Intermediate half-life, slower onset. Metabolized via glucuronidation (spared in liver failure). | The workhorse. Considered the safest choice for elderly patients and those with significant liver impairment because its metabolism is less affected. | Because it’s shorter-acting, it may require more frequent dosing than diazepam and can lead to more “breakthrough” symptoms if doses are missed. |
| Chlordiazepoxide (Librium) | The “classic” agent. Very long half-life, similar to diazepam. Available only orally. | Stable patients who can tolerate oral medications and are expected to have a mild-to-moderate withdrawal course. | Not available IV, so it cannot be used for patients who are NPO or in severe withdrawal requiring rapid IV treatment. Like diazepam, it should be used with caution in liver failure. |
Your CIWA Verification Checklist
- Right Patient, Right Drug? The most important check. If the order is for diazepam in an 80-year-old with cirrhosis, you must intervene. The Script: “Hi Dr. Jones, I’m verifying the CIWA order set for your patient in 612. I see diazepam is ordered. Given the patient’s age and history of advanced liver disease, I’m concerned about the risk of oversedation from the long-acting metabolites. Our hospital protocol recommends lorazepam for this patient population as it’s much safer. Would you be okay if I switched the order to our symptom-triggered lorazepam protocol?”
- Symptom-Triggered vs. Fixed-Dose? The modern standard of care is symptom-triggered therapy (giving meds only when the CIWA score is high). A fixed-dose regimen (e.g., “Lorazepam 2mg IV q6h scheduled”) is generally less safe, using more benzodiazepines and increasing sedation risk. If you see a fixed-dose regimen, it’s an opportunity to educate and recommend a switch to a symptom-triggered protocol.
- Are the Adjuncts Ordered? The “banana bag” isn’t just folklore. Thiamine is absolutely critical for preventing Wernicke-Korsakoff syndrome, a catastrophic and irreversible form of brain damage. Every patient admitted for alcohol withdrawal needs empiric thiamine. The rule is “Thiamine before glucose.” Giving IV dextrose to a thiamine-deficient patient can precipitate acute Wernicke’s. Ensure Thiamine 100mg (or more) and Folic Acid 1mg are on board.
36.5.4 When the Protocol Fails: Managing Refractory Delirium Tremens
Sometimes, despite aggressive benzodiazepine therapy, a patient’s withdrawal continues to escalate. They develop profound agitation, hallucinations, and extreme autonomic instability (tachycardia, hypertension, fever). This is Delirium Tremens (DTs), and it is a medical emergency often requiring ICU-level care. When a patient requires massive doses of benzodiazepines (e.g., >40mg of lorazepam in a few hours) and is still not controlled, they are considered to have refractory DTs. At this point, benzodiazepines alone are not enough, and you must escalate therapy.
Escalation Therapy: High-Risk, High-Reward
Managing refractory DTs involves using second-line agents that require intensive monitoring, usually in an ICU setting. Your role is to be the expert consultant on these high-risk options.
| Agent | Mechanism & Rationale | Pharmacist’s Role & Key “Gotchas” |
|---|---|---|
| Phenobarbital | A barbiturate that also acts on the GABA-A receptor, but at a different site than benzodiazepines. It provides synergistic GABAergic effects and can often “break through” the benzodiazepine resistance. | This is your most common and effective second-line agent. You must be an expert on the protocol. A common strategy is to give a loading dose of 10 mg/kg IV, followed by smaller supplemental doses. Gotcha: Phenobarbital has a very long half-life and can cause profound and prolonged respiratory depression, especially when combined with benzodiazepines. The patient MUST be in a monitored setting. |
| Propofol | A general anesthetic that is also a potent GABA-A agonist. Used as a continuous infusion for patients who are intubated and mechanically ventilated due to severe DTs. | Your role is in verifying the infusion order and ensuring it’s dosed correctly (typically in mcg/kg/min). Gotcha: Watch for propofol-related infusion syndrome (PRIS) with high doses or prolonged use. Monitor triglycerides and for signs of metabolic acidosis. |
| Dexmedetomidine (Precedex) | A centrally acting alpha-2 agonist. It does NOT treat the underlying withdrawal but is excellent for controlling the autonomic hyperactivity (tachycardia, hypertension) and providing sedation without causing respiratory depression. | Often used as an adjunct to benzodiazepines, not as a replacement. It can help reduce the total amount of benzodiazepines needed. Gotcha: It can cause significant bradycardia and hypotension. It is not a stand-alone treatment for seizures. |
36.5.5 Bonus Deep Dive: The “Banana Bag” Order
You will frequently see an order for a “Banana Bag.” This is not an official NDC, but rather hospital slang for an intravenous fluid bag, typically Normal Saline or D5W, containing a combination of vitamins and minerals. Its characteristic yellow color, derived from the multivitamin infusion, gives it its name. The primary use is for the empiric repletion of common nutritional deficiencies in patients at high risk, most notably those with chronic or acute alcohol use disorder, but also in patients with severe malnutrition for other reasons.
Your role is to ensure that this “cocktail” is appropriate, that its individual components are dosed correctly, and that it is prepared and administered safely. It is a classic example of translating a piece of clinical shorthand into a safe and effective medication order.
Masterclass Visual Guide: Anatomy of a Banana Bag
The Core Four Components
Thiamine (Vitamin B1)
100 mg
The “Why”: Prevents Wernicke-Korsakoff syndrome, a catastrophic neurologic outcome of thiamine deficiency precipitated by giving glucose.
Folic Acid (Vitamin B9)
1 mg
The “Why”: Corrects folate deficiency, which is common in alcohol use disorder and can lead to macrocytic anemia.
Multivitamin for Infusion (MVI)
1 Vial
The “Why”: Provides a broad range of other essential B-vitamins and Vitamin C. This is what gives the bag its yellow color.
Magnesium Sulfate
1-2 grams
The “Why”: Corrects hypomagnesemia, which is nearly universal in these patients and can worsen withdrawal symptoms and arrhythmias.
These components are typically added to a 1-Liter bag of Normal Saline (0.9% NaCl) or D5W and infused over 4-8 hours.
Your “Banana Bag” Verification Checklist
- Check the Base Fluid: Is the patient a brittle diabetic who might become hyperglycemic from D5W? Is the patient hypernatremic, making Normal Saline a poor choice? Lactated Ringer’s is often a good alternative.
- Confirm the Thiamine Dose: 100 mg is the standard prophylactic dose. If the patient is suspected of already having Wernicke’s encephalopathy, the dose should be much higher (e.g., 500 mg IV TID), and this requires a call to the provider.
- Check the Labs (The “Gotcha”): Before you verify the magnesium, you must check the patient’s baseline serum magnesium and potassium levels. While 1-2 grams is a safe empiric dose for most, if the patient is coincidentally in renal failure with a high baseline magnesium, adding more could be dangerous.
- The Rule of “Thiamine Before Glucose”: Always ensure that in any patient receiving IV dextrose for hypoglycemia who is also at risk for alcohol withdrawal, thiamine is administered first (or concurrently) to prevent precipitating Wernicke’s.
EHR Pharmacy Order Entry Simulation (Banana Bag)
When a “Banana Bag” is ordered, you do not verify a single item. You must enter and verify each component as a separate “additive” to the base IV fluid. This ensures proper charging, inventory management, and clear instructions for the IV room technician.
Order: “Banana Bag in NS, infuse over 6 hours”
Component
Dose
Instructions
Sodium Chloride 0.9%
1000 mL
Base IV Fluid. Infuse at 167 mL/hr for 6 hours.
ADDITIVES:
Thiamine HCl
100 mg
Folic Acid
1 mg
Multivitamin Infusion
1 vial
Magnesium Sulfate
2 grams
After verifying each additive for appropriateness, you would finalize the order, which generates a single, comprehensive label for the IV room to compound.
