Alcohol withdrawal — ABIM Board MCQ

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EasyGeneral Internal MedicineAlcohol withdrawalABIM Board

A 54-year-old man with alcohol use disorder is hospitalized 10 hours after his last drink. He has tremor, diaphoresis, agitation, hypertension, and tachycardia. He is awake, oriented, and able to participate reliably in symptom assessment. His Clinical Institute Withdrawal Assessment for Alcohol–Revised (CIWA-Ar) score is 18. Which of the following is the most appropriate management?

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Correct answer: B — Symptom-triggered lorazepam therapy

This patient has clinically significant alcohol withdrawal, demonstrated by tremor, agitation, autonomic hyperactivity, and a CIWA-Ar score of 18. Benzodiazepines are first-line therapy because they treat withdrawal symptoms and reduce the risks of seizures and withdrawal delirium. Because he is alert, can complete serial CIWA-Ar assessments, and is in a monitored hospital setting, symptom-triggered lorazepam is appropriate. Haloperidol may occasionally be used as an adjunct for refractory agitation or hallucinations but does not prevent withdrawal seizures and should not be used alone. Beta-blockers can reduce autonomic findings but may mask worsening withdrawal and are not definitive monotherapy. Disulfiram is intended to support abstinence after acute withdrawal has resolved. Fluid restriction does not treat alcohol withdrawal.

Reference: American Society of Addiction Medicine. The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management, inpatient management and benzodiazepine dosing-regimen sections. 2020. https://www.ncbi.nlm.nih.gov/books/NBK441882/