Rationale for using chlordiazepoxide
Chlordiazepoxide is a benzodiazepine that controls symptoms of acute alcohol withdrawal, such as agitation, tremor, anxiety, autonomic overactivity and seizures. The drug prevents an established alcohol withdrawal syndrome progressing further to the pre-delirium tremens or delirium tremens (DTs) state.
Patients admitting to over 10 units of alcohol per day are likely to experience some withdrawal symptoms.
Chlordiazepoxide reducing regime:
Day 1 20mg qds
Day 2 20mg qds
Day 3 20mg qds
Day 4 15mg qds
Day 5 10mg qds
Day 6 5mg qds
Day 7 5mg bd
Chlordiazepoxide 20mg prn should also be prescribed. If withdrawal symptoms are severe, or there is a past history of withdrawal fits, a higher starting dose may be prescribed, e.g. 30 or 40mg qds. Anticonvulsants, e.g. carbamazepine, are likely to be ineffective if started in hospital. Give diazepam PR or IV if withdrawal seizures occur.
Elderly patients
Halve the dose of chlordiazepoxide, e.g.
Days 1-3 10mg qds
Day 4 10mg tds
Day 5 5mg qds
Day 6 5mg bd
Day 7 5mg od
Prescribe 10mg prn.
Discharge
This regime is intended for use only in hospital. It should only be continued on discharge if follow-up by an Alcohol Treatment Service has been arranged for the patient. Sufficient chlordiazepoxide and vitamins must be supplied until any appointment date. The combination of alcohol and benzodiazepines is potentially harmful. See below for referral details.
Monitoring
Adverse effects include drowsiness, sedation, unsteadiness, ataxia, fatigue, confusion, weakness, dizziness, vertigo and syncope; the first four are common. Adverse effects are dose related and usually occur during the first few days of therapy. Geriatric or debilitated patients, and patients with liver disease or low serum albumin are most likely to experience these adverse CNS effects.
Vitamin supplementation
Absorption of oral thiamine from the GI tract is poor and saturates at 5-10mg thiamine. The parenteral route must be used in the treatment of established Wernicke's encephalopathy or for prophylaxis in high-risk patients.
Incipient or established
Wernicke's encephalopathy
Characterised in most cases by confusion +/- ataxia, memory
disturbance and opthalmoplegia.
Give 2 pairs TDS of Pabrinex* ampoules IV for 3 days. Give in 100ml
normal saline over 30 minutes.
Subsequently, give 1 pair of ampoules IV once daily for 3-5 days or
until symptoms subside.
High risk patients without Wernicke's encephalopathy
Look for significant weight loss, severe withdrawal, increasing
memory problems/black outs.
Give 1 pair of Pabrinex* ampoules IV once daily for 3 days. Give as above.
All patients should receive:
Thiamine 50mg QDS
Vitamin B Co Strong ii BD for 10 days.
Continue only if the patient's diet is inadequate.
*There is a risk of anaphylaxis with IV Pabrinex. Ensure that facilities for management of anaphylaxis are available when the infusion is administered.
Referral to community alcohol services
Main referral pathway to Manchester Alcohol Service is:
Community Alcohol Team 0161 223 3770
Other services:
Brian Hore Unit, Withington (day patient service) 0161 611 4166
Turning Point, Smithfield (in-patient unit) 0161 839 8829
Adapted from Hope Hospital guidelines with advice from Dr C Daly, consultant psychiatrist, Brian Hore Unit.
Latest revision: 11 August 2003