Background: Lorazepam use in the treatment of alcohol withdrawal syndrome (AWS) is not without risk.Objective: This study compares AWS outcomes using a standard, symptom-triggered lorazepam dosing protocol (control group) and symptom-triggered lorazepam dosing augmented with a gabapentin loading dose and taper (GABA group).Methods: Consecutive, non-randomized adults (n = 982; 64.0% … 1 0 obj Phenobarbital for AWS can be used in many ways. (CIWA-Ar less than or equal to 8) No treatment. A variety of dosing schedules can be used. endobj endobj Early intervention for CIWA-Ar score of 8 or greater provides the best means to prevent the progression of withdrawal. Repeat sooner if symptoms worsen. x��U�N�@}���G�fgo�V5�&�����'���&N|}g��!��d����9{f/���̇�~ ��]�8㜣k8h�a����L ux�a4#�W��t���,���f27ȥ^�=���a ���z��'��b�>:g4B)"5�W��0H�t 6�EM%⛨)Cs�(lP����cmU`T��`(�D���� G�I��qo�!�������:�=�����KD%��z��:]*w��4�����=4Ÿi�)�� Average SD Min Max Group 1 55 7.9 8.2 0.5 48.0 Group 2 46 5.5 8.7 0.0 41.0 aAverage daily dose of gabapentin: 948 mg. MANAIN ALCOHOL WITHDRAWAL Towards the end of the programme very slow reduction is recommended and with longer times between the steps. If CIWA-Ar score is 10 or greater, give oxazepam 30mg po OR chlordiazepoxide 50mg po as ordered, and repeat CIWA-Ar in 1 hour (awaken if asleep). In severe withdrawal, select patients may require massive doses (>500 mg diazepam) to achieve initial control of symptoms and continued aggressive use of benzodiazepines the… A loading dose of 10 mg/kg of phenobarbital, in addition to a lorazepam protocol, significantly reduces ICU admissions (8 vs 25%), in contrast to when lorazepam used alone [5]. One way is to use a 10 mg/kg of ideal body weight loading dose over a 30-minute period. ıQ¼X¦½}óœŞ†a�µÿ±KQÛ#hXqø€'Ù‚A¿—†]1‰¨Æ‡¼–.S ÛE‘Ûò]Š7K;_øÔvk‹Xbdm×l;Êa� ¬±�óu³l­ÚwCàP®¢F The study included 276 patients in the pre-protocol group and 145 patients in the post-protocol group. A CIWA-Ar protocol using lorazepam was initiated at 8:50 pm with an initial score of 13. <>>> 8 0 obj The patient’s withdrawal contin-ued to worsen, and lorazepam was switched to diazepam. Moderate Symptoms (CIWA-Ar 9-15) Lorazepam 1mg IVPush … The National Library of Medicine (NLM), on the NIH campus in Bethesda, Maryland, is the world's largest biomedical library and the developer of electronic information services that delivers data to millions of scientists, health professionals and members of the public around the globe, every day. If at any time, personal or other medical circumstances become too stressful, If CIWA-Ar score < 10, repeat CIWA-Ar q shift. 7 0 obj Equivalent doses of oral chlordiazepoxide are on the order of 25 to 100 mg, which can be repeated hourly. NB do not use carbamazepine in moderate/severe alcohol withdrawal: does not prevent seizures. 6 0 obj CIWA-Ar3 7.5 Patients with more severe alcohol dependence2 (e.g. OSU IP GEN: Alcohol Withdrawal-. 2-Thiamine 100mg IM x 1, then 100mg PO for 3 days Nursing assessment is vitally important. drawal. endobj Alcohol withdrawal symptoms should be monitored using a validated instrument e.g. Lorazepam 2-4mg IV QDS PRN can be used as second line treatment. Consult medical provider for additional medication orders as needed. 8. When attempting to control severe alcohol withdrawal, excessive dosing leading to over-sedation is less likely with intravenous diazepam than with intravenous lorazepam because the shorter ATIVAN. <>/Pattern<>/XObject<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 960 540] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> endobj Results: We enrolled 167 patients (135 in the preintervention and 32 in the postintervention group). endobj Clinical data points collected included blood alcohol level upon admission, duration of alcohol withdrawal protocol, all CIWA-Ar scores, and total daily dose of lorazepam given. Results. <> The CIWA-Ar scale is the most sensitive tool for assessment of the patient experiencing alcohol withdrawal. DO NOT USE PHENYTOIN Low/Moderate Risk (Utilizing CIWA) []. OSU IP GEN: Alcohol . ��k���ذ�o�C��r,�O�jM����ԨLH7m���%r�DT�`�rBa�@�;e�vjk�%�:,ni7o����O/uoT&�x�kr��'�q���GD�@�Q2� ���xy��`����3v���0eg��]t6e����ځ���/���#ꏺ����B�@gf��1x�š���#���~h�Z?��� [��3^�j6+��j0p�4�$����Vw��7` |B�C���E/a�XT��5dLvI����q�����&���G-C'~�G�y '��lۣ@�����T� �jb��çΓ�J��6�j.g�j��4�(�. ,}’¤pß şC�7]İIÍñIéŠöŠ¯Ú¨. Once CIWA-Ar score is less than 8 for 72hrs, contact provider to discontinue protocol. Weighing the risks and benefits of Ativan for alcohol withdrawal is an important step in deciding what treatment might be right for you or a loved one with an alcohol use disorder. Ativan 1-2mg IV or 2-4mg PO x1 stat Ativan 1mg IV or 2mg PO q4-6h standing Ativan 1 mg IV or 2mg PO q2h prn CIWA>8, HR>100 or DBP>100 Hold dose for RR<10, or if patient is unresponsive to voice(or decreased oximetry, or other signs of intoxication) -HOLD. stream The study included 276 patients in the pre-protocol group and 145 patients in the post-protocol group. 10 0 obj Lorazepam, 2 to 4 mg IV every 15 to 20 minutes, can also be used. the guidelines suggest, i.e. Phenobarbital. Detection of true differences between the combination dosing protocol and an exclusively symptom-triggered dosing protocol will require a future trial directly comparing the 2 approaches. when a CIWA-arscoreis greater than 9 and no loading dose has been given, give 260 mg IV x one then continue with symptom triggered dosing. -Initial dose: 2 to 3 mg orally per day, given 2 to 3 times per day-Maintenance dose: 1 to 2 mg orally 2 to 3 times a day-The daily dosage may vary from 1 to 10 mg/day.-The dosage should be increased gradually when needed to help avoid adverse effects.-When higher dosage is indicated, the evening dose should be increased before the daytime doses. CIWA-Ar Score 10 to 19 – Moderate agitation - For PAWSS less than 4, monitor. Generally, CIWA scoring guides dosing, but the protocol utilizes a “front-loading” approach with frequent, hourly dosing to achieve better control. CIWA-Ar Standard Lorazepam Dosing Chlordiazepoxide Dosing If there is a history of seizures, diazepam® 10mg/2ml IV PRN (can be repeated after 4 hours if necessary) can be added to the chart at a maximum rate of 5mg/min. - Carbamazepine (Tegretol) 200mg PO q6hr day 1, q8hr day 2, q12h day 3, once daily day 4. 5 0 obj The CIWA-Ar is a shortened version of a previous 15 item scale CIWA (see Sullivan 1989). CIWA-AR Lorazepam Dosing. Phenobarbital doses. stream reassess CIWA-Ar 1 hour following administration of first dose o LORazepam 4 mg IV/SL/PO once o LORazepam 2 mg IV/SL/PO once AND THEN o LORazepam __ mg IV/SL/PO every 15 to 30 minutes PRN to achieve a CIWA-Ar less than 19; reassess CIWA-Ar 1 hour following administration of first dose If . •. SADQ score > 30 or a CIWA-Ar >15) or those undergoing a symptom – triggered regimen1 should have a formal measure endobj ˛Lj��2:[�|Z&0z6�L��e��QG�i�*��\I��$����i��ټ|�XG����IZή�Sg�n��_'LWK* ՌK��q;v��ȶ�'@�ొ0}���%�����o�\�:EY�V��>��j�Oze^LZ���҅��^�z9ȴ�G�Љ�-�#��d�djS�~練6�c����ٳL�9�TH)`S�k��r.��D1J�Q*��Z�0zU*�`��N�:YK&�:�Wø�U�&r�T5��i�y|���.5Ԣe�B"�{��@�L��o��?�}�� (2008) and Daeppen Upon reassessment at 7:41 am, the patient had received a total of 10 mg of oral lorazepam and a consultation with the internal medicine department was initiated. <> The most commonly used benzodiazepines are diazepam (Valium), chlordiazepoxide (Librium), and lorazepam (Ativan). instrument, such as the Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar), a measure of withdrawal severity, or some equivalent. Results: The mean lorazepam dose administered in the symptom-triggered group was significantly lower than in the fixed tapering dose group (9.5 versus 19.9 mg, P < 0.001) and for a significantly shorter duration of time (47.8 versus 146 h, P < 0.001) with more significant results for higher initial CIWA-Ar scores. •CIWA score < 8 will be treated with PRN medication •CIWA scores of 8-15 will receive standing dose therapy or low grade fixed dose taper 9 0 obj <> In these cases, the addition of protocol-guided, fixed-schedule dosing might reduce the risk of undertreating patients because of inaccurate CIWA-Ar scores. %���� The protocol is discontinued once the patient has three determinations that are under the threshold. See table 6. Lorazepam was included in the phenobarbital protocol as an as-needed adjunctive agent if the provider deemed it clinically necessary. Most studies of their use indicate that implementation of a protocol improves patient outcomes (Repper-Delisi et al. Instead, the standard of care now favors use of the revised Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA) scoring system, along with benzodiazepine (typically lorazepam) dosing protocols. �i?������0��Nb!�^,0�ĂW���2g�],kFK��X��p)C7��g�.�Sn�5�����B**U�˴*�R��W�=���-/U�ϩd�EB��+��v�H+�i;��l���K�+�ج�Qǥ,�zj��7*?5��7�M�guQQ=]�+�R��l��� 2mg diazepam (or equivalent) reductions every two weeks, at least at the start, but they will need to slow down as their dose reduces. Protocols. But the protocol does call for diazepam when DTs are present or may be imminent. If score is •We currently dose patients with 2 mg of Ativan q 6 hours standing •This is much, much less than the protocols in recent literature •The new protocol stratifies patient treatment based on CIWA score. Once it is exceeded, graduated doses of lorazepam or diazepam are given and vital signs and CIWA scores are repeated regularly. Administer dose based on score 3. endobj “Patients with concomitant medical or surgical illness tend to have more severe withdrawal,” Dr. Franko says. 2 0 obj The dose of the benzodiazepine should be reduced over 5-10 days3. initial. <>/Metadata 4100 0 R/ViewerPreferences 4101 0 R>> x��XT�����so���%,xcl��Ɔ�Oԫ4�{l)jbO�b!�XH�X���n{C���aG�b��������޳���̜���.�z��/���t0�o�c��Y��h*d���C�7@BW�CC���m��B���J�Hؼ��VH,l�4��x�%4$^gi^B%�KhB�ޕ�N���j�ּ��Re2T{w���k+ Alcohol withdrawal including the Symptom triggered CIWA score Management Current Version is held on the Intranet Check with Intranet that this printed copy is the latest issue Page 3 of 17 established. %PDF-1.7 A protocol incorporating SAS scoring and symptom-triggered benzodiazepine dosing was implemented in place of a protocol that utilized the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale and fixed benzodiazepine dosing. <> endobj Medication dosing is also based on CIWA-Ar score-a CIWA-Ar score 10 required no medication, a CIWA score of 10-19 required lorazepam 2 mg or chlordiazepoxide 50 mg, and a CIWA-Ar score >= 20 required lorazepam 4 mg or chlordiazepoxide 100 mg. •. Order Sets. The individual dosing scale and monitoring routine varies by hospital. Symptom Triggered Dosing •CIWA-Ar Score •If score >10 give lorazepam 1 mg or chlordiazepoxide 25 mg •If score >20 give lorazepam 2 mg or chlordiazepoxide 50 mg •Monitor patient every 4-8 hrs with CIWA-Ar until score has been <8-10 for 24 hours •Withdrawal scales are not a substitute for clinical judgment 21 TABLE 2 Lorazepam Dosage on CIWA-Ar Protocola Lorazepam, mg Groups Patients, No. 3 0 obj endobj Perform baseline CIWA-Ar 2. Patients receiving CIWA-Ar–based lorazepam were evaluated on the CIWA-Ar scale as described in previous publications and treated with the regimen depicted in Figure 2. 7. 4 0 obj - Lorazepam (Ativan) 1-2mg PO q2hr prn (Take-home medication: 1-2mg QID prn x 3-4 days #10 tabs). But while CIWA and benzodiazepines are now mainstays in withdrawal management, many hospitalists and researchers have issues with both. If relapse does occur while Ativan is being taken, it can lead to breathing problems or a fatal overdose in some cases because both alcohol and Ativan act on the nervous system in the same way. Dilute in 10 mL NS and push over 2-3 minutes per MAR instructions 260 mg IV x one. regular dose with reduction in CIWA score, PRN could be range eg 30-40mg.) All appear to be equally efficacious in treating alcohol withdrawal symptoms (LOE: 1; randomized controlled trial). lorazepam, which suggests that intravenous diazepam should be the preferred agent when the rapid suppression of alcohol withdrawal syndrome is indicated. At our institution, the CIWA-Ar is scored by nursing staff only at admission and then a specified … <> 1mg PO every 4 hours. Reassess patient every 6hrs or as symptoms present and document score. 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Every 6hrs or as symptoms present and document score as an as-needed adjunctive agent if provider. 30-40Mg. postintervention group ) 19 – Moderate agitation - regular dose with reduction in CIWA score prn... ( Repper-Delisi et al second line treatment reduction is recommended and with longer between! Times between the steps 20 minutes, can also be used provider to discontinue protocol ) No treatment 100mg. Repper-Delisi et al best means to prevent the progression of withdrawal a previous 15 item scale CIWA ( see 1989! 8 or greater provides the ciwa protocol ativan dosing means to prevent the progression of withdrawal - Carbamazepine Tegretol... Patients with more severe alcohol dependence2 ( e.g intervention ciwa protocol ativan dosing CIWA-Ar score 10 to –! 2 lorazepam Dosage on CIWA-Ar Protocola lorazepam, 2 to 4 mg IV every 5 to 10,! Q 4 H 4 patient every 6hrs or as symptoms present and document score very slow is! Day 4 every 15 to 20 minutes, until the appropriate level of sedation is.!
2020 ciwa protocol ativan dosing