Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

1.1 Acute alcohol withdrawal

1.1.1 Admission to hospital

1.1.1.1 For people in acute alcohol withdrawal with, or who are assessed to be at high risk of developing, alcohol withdrawal seizures or delirium tremens, offer admission to hospital for medically assisted alcohol withdrawal. [2010]

1.1.1.2 For young people under 16 years who are in acute alcohol withdrawal, offer admission to hospital for physical and psychosocial assessment, in addition to medically assisted alcohol withdrawal. [2010]

1.1.1.3 For certain vulnerable people who are in acute alcohol withdrawal (for example, those who are frail, have cognitive impairment or multiple comorbidities, lack social support, have learning difficulties or are 16 or 17 years), consider a lower threshold for admission to hospital for medically assisted alcohol withdrawal. [2010]

1.1.1.4 For people who are alcohol dependent but not admitted to hospital, offer advice to avoid a sudden reduction in alcohol intake[1] and information about how to contact local alcohol support services. [2010]

1.1.2 Assessment and monitoring

1.1.2.1 Healthcare professionals who care for people in acute alcohol withdrawal should be skilled in the assessment and monitoring of withdrawal symptoms and signs. [2010]

1.1.2.2 Follow locally specified protocols to assess and monitor patients in acute alcohol withdrawal. Consider using a tool (such as the Clinical Institute Withdrawal Assessment – Alcohol, revised [CIWA–Ar] scale[2]) as an adjunct to clinical judgement. [2010]

1.1.2.3 People in acute alcohol withdrawal should be assessed immediately on admission to hospital by a healthcare professional skilled in the management of alcohol withdrawal. [2010]

1.1.3 Treatment for acute alcohol withdrawal

1.1.3.1 Offer pharmacotherapy to treat the symptoms of acute alcohol withdrawal as follows:

  • Consider offering a benzodiazepine[3] or carbamazepine[4].

  • Clomethiazole[5] may be offered as an alternative to a benzodiazepine or carbamazepine. However, it should be used with caution, in inpatient settings only and according to the summary of product characteristics. [2010]

1.1.3.2 People with decompensated liver disease who are being treated for acute alcohol withdrawal should be offered advice from a healthcare professional experienced in the management of patients with liver disease. [2010]

1.1.3.3 Offer information about how to contact local alcohol support services to people who are being treated for acute alcohol withdrawal. [2010]

1.1.3.4 Follow a symptom-triggered regimen[6] for drug treatment for people in acute alcohol withdrawal who are:

  • in hospital or

  • in other settings where 24-hour assessment and monitoring are available. [2010]

1.1.4 Management of delirium tremens

1.1.4.1 In people with delirium tremens, offer oral lorazepam[7] as first-line treatment. If symptoms persist or oral medication is declined, offer parenteral lorazepam[7] or haloperidol[8]. [2010, amended 2017]

1.1.4.2 If delirium tremens develops in a person during treatment for acute alcohol withdrawal, review their withdrawal drug regimen. [2010]

1.1.5 Management of alcohol withdrawal seizures

1.1.5.1 In people with alcohol withdrawal seizures, consider offering a quick-acting benzodiazepine (such as lorazepam[7]) to reduce the likelihood of further seizures. [2010]

1.1.5.2 If alcohol withdrawal seizures develop in a person during treatment for acute alcohol withdrawal, review their withdrawal drug regimen. [2010]

1.1.5.3 Do not offer phenytoin to treat alcohol withdrawal seizures. [2010]

1.2 Wernicke's encephalopathy

1.2.1.1 Offer thiamine to people at high risk of developing, or with suspected, Wernicke's encephalopathy. Thiamine should be given in doses toward the upper end of the 'British national formulary' range. It should be given orally or parenterally as described in recommendations 1.2.1.2 to 1.2.1.4. [2010]

1.2.1.2 Offer prophylactic oral thiamine to harmful or dependent drinkers:

1.2.1.3 Offer prophylactic parenteral thiamine followed by oral thiamine to harmful or dependent drinkers:

  • if they are malnourished or at risk of malnourishment or

  • if they have decompensated liver disease

and in addition

  • they attend an emergency department or

  • are admitted to hospital with an acute illness or injury. [2010]

1.2.1.4 Offer parenteral thiamine to people with suspected Wernicke's encephalopathy. Maintain a high level of suspicion for the possibility of Wernicke's encephalopathy, particularly if the person is intoxicated. Parenteral treatment should be given for a minimum of 5 days, unless Wernicke's encephalopathy is excluded. Oral thiamine treatment should follow parenteral therapy. [2010]

1.3 Alcohol-related liver disease

1.3.1 Assessment and diagnosis of alcohol-related liver disease

1.3.1.1 Exclude alternative causes of liver disease in people with a history of harmful or hazardous drinking who have abnormal liver blood test results. [2010]

1.3.1.2 Refer people to a specialist experienced in the management of alcohol-related liver disease to confirm a clinical diagnosis of alcohol-related liver disease. [2010]

1.3.1.3 Consider liver biopsy for the investigation of alcohol-related liver disease. [2010]

1.3.1.4 When considering liver biopsy for the investigation of alcohol-related liver disease:

  • take into account the small but definite risks of morbidity and mortality

  • discuss the benefits and risks with the patient and

  • ensure informed consent is obtained. [2010]

1.3.1.5 In people with suspected acute alcohol-related hepatitis, consider a liver biopsy to confirm the diagnosis if the hepatitis is severe enough to require corticosteroid treatment. [2010]

1.3.2 Referral for consideration of liver transplantation

1.3.2.1 Refer patients with decompensated liver disease to be considered for assessment for liver transplantation if they:

  • still have decompensated liver disease after best management and 3 months' abstinence from alcohol and

  • are otherwise suitable candidates for liver transplantation. [2010, amended 2017]

1.3.3 Corticosteroid treatment for alcohol-related hepatitis

1.3.3.1 Offer corticosteroid[9] treatment to people with severe alcohol-related hepatitis and a discriminant function[10] of 32 or more, only after:

  • effectively treating any active infection or gastrointestinal bleeding that may be present

  • controlling any renal impairment

  • discussing the potential benefits and risks with the person and their family members or carers (as appropriate), explaining that corticosteroid treatment:

    • has been shown to improve survival in the short term (1 month)

    • has not been shown to improve survival over a longer term (3 months to 1 year)

    • has been shown to increase the risk of serious infections within the first 3 months of starting treatment. [2017]

1.3.4 Nutritional support for alcohol-related hepatitis

1.3.4.1 Assess the nutritional requirements of people with acute alcohol-related hepatitis. Offer nutritional support if needed[11] and consider using nasogastric tube feeding. [2010]

1.4 Alcohol-related pancreatitis

1.4.1 Diagnosis of chronic alcohol-related pancreatitis

1.4.1.1 To inform a diagnosis of chronic alcohol-related pancreatitis use a combination of:

  • the person's symptoms

  • an imaging modality to determine pancreatic structure and

  • tests of pancreatic exocrine and endocrine function. [2010]

1.4.1.2 Use computed tomography as the first-line imaging modality for the diagnosis of chronic alcohol-related pancreatitis in people with a history and symptoms suggestive of chronic alcohol-related pancreatitis. [2010]

1.4.2 Pancreatic surgery versus endoscopic therapy for chronic alcohol-related pancreatitis

1.4.2.1 Refer people with pain from chronic alcohol-related pancreatitis to a specialist centre for multidisciplinary assessment. [2010]

1.4.2.2 Offer surgery, in preference to endoscopic therapy, to people with pain from large-duct (obstructive) chronic alcohol-related pancreatitis. [2010]

1.4.2.3 Offer coeliac axis block, splanchnicectomy or surgery to people with poorly controlled pain from small-duct (non-obstructive) chronic alcohol-related pancreatitis. [2010]

1.4.3 Prophylactic antibiotics for acute alcohol-related pancreatitis

1.4.3.1 Do not give prophylactic antibiotics to people with mild acute alcohol-related pancreatitis, unless otherwise indicated. [2010]

1.4.4 Nutritional support for acute alcohol-related pancreatitis

1.4.4.1 Offer nutritional support[11]to people with acute alcohol-related pancreatitis:

  • early (on diagnosis) and

  • by enteral tube feeding rather than parenterally where possible. [2010]

1.4.5 Enzyme supplementation for chronic alcohol-related pancreatitis

1.4.5.1 Offer pancreatic enzyme supplements to people with chronic alcohol-related pancreatitis who have symptoms of steatorrhoea or poor nutritional status due to exocrine pancreatic insufficiency. [2010]

1.4.5.2 Do not prescribe pancreatic enzyme supplements to people with chronic alcohol-related pancreatitis if pain is their only symptom. [2010]

Terms used in this guideline

Acute alcohol withdrawal

The physical and psychological symptoms that people can experience when they suddenly reduce the amount of alcohol they drink if they have previously been drinking excessively for prolonged periods of time.

Alcohol dependence

A cluster of behavioural, cognitive and physiological factors that typically include a strong desire to drink alcohol and difficulties in controlling its use. Someone who is alcohol-dependent may persist in drinking, despite harmful consequences. They will also give alcohol a higher priority than other activities and obligations. For further information, please refer to: 'Diagnostic and statistical manual of mental disorders' (DSM-IV) (American Psychiatric Association 2000) and 'International statistical classification of diseases and related health problems – 10th revision' (ICD-10) (World Health Organization 2007).

Alcohol-related hepatitis

Alcoholic hepatitis.

Coeliac axis block

Pain relief by nerve block of the coeliac plexus.

CIWA–Ar scale

The Clinical Institute Withdrawal Assessment – Alcohol, revised (CIWA–Ar) scale is a validated 10-item assessment tool that can be used to quantify the severity of the alcohol withdrawal syndrome, and to monitor and medicate patients throughout withdrawal.

Decompensated liver disease

Liver disease complicated by jaundice, ascites, variceal bleeding or hepatic encephalopathy.

Harmful drinking

A pattern of alcohol consumption that is causing mental or physical damage.

Hazardous drinking

A pattern of alcohol consumption that increases someone's risk of harm. Some would limit this definition to the physical or mental health consequences (as in harmful use). Others would include the social consequences. The term is currently used by the World Health Organization to describe this pattern of alcohol consumption. It is not a diagnostic term.

Malnourishment

A state of nutrition in which a deficiency of energy, protein and/or other nutrients causes measurable adverse effects on tissue/body form, composition, function or clinical outcome.

Medically assisted alcohol withdrawal

The deliberate withdrawal from alcohol by a dependent drinker under the supervision of medical staff. Prescribed medication may be needed to relieve the symptoms. It can be carried out at home, in the community or in a hospital or other inpatient facility.

Splanchnicectomy

Surgical division of the splanchnic nerves and coeliac ganglion.



[1] While abstinence is the goal, a sudden reduction in alcohol intake can result in severe withdrawal in dependent drinkers.

[2] Sullivan JT, Sykora K, Schneiderman J et al. (1989) Assessment of alcohol withdrawal: the revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA–Ar). British Journal of Addiction 84:1353-1357.

[3] Benzodiazepines are used in UK clinical practice in the management of alcohol-related withdrawal symptoms. Diazepam and chlordiazepoxide have UK marketing authorisation for the management of acute alcohol withdrawal symptoms. However, at the time of publication (April 2017), alprazolam, clobazam and lorazepam did not have UK marketing authorisations for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information. In addition, the summary of product characteristics (SPC) for alprazolam advises that benzodiazepines should be used with extreme caution in patients with a history of alcohol abuse. The SPC for clobazam states that it must not be used in patients with any history of alcohol dependence (due to increased risk of dependence). The SPC for lorazepam advises that use in individuals with a history of alcoholism should be avoided (due to increased risk of dependence).

[4] Although carbamazepine is used in UK clinical practice in the management of alcohol-related withdrawal symptoms, at the time of publication (April 2017), it did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information.

[5] Clomethiazole has a UK marketing authorisation for the treatment of alcohol withdrawal symptoms where close hospital supervision is also provided. However, at the time of publication (April 2017), the SPC advises caution in prescribing clomethiazole for individuals known to be addiction-prone and to outpatient alcoholics. It also advises against prescribing it to patients who continue to drink or abuse alcohol. Alcohol combined with clomethiazole, particularly in alcoholics with cirrhosis, can lead to fatal respiratory depression even with short-term use. Clomethiazole should only be used in hospital under close supervision or, in exceptional circumstances, on an outpatient basis by specialist units when the daily dosage must be monitored closely.

[6] A symptom-triggered regimen involves treatment tailored to the person's individual needs. These are determined by the severity of withdrawal signs and symptoms. The patient is regularly assessed and monitored, either using clinical experience and questioning alone or with the help of a designated questionnaire such as the CIWA–Ar. Drug treatment is provided if the patient needs it and treatment is withheld if there are no symptoms of withdrawal.

[7] Although lorazepam is used in UK clinical practice in the management of delirium tremens, at the time of publication (April 2017), it did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information. In addition, the SPC advises that use in individuals with a history of alcoholism should be avoided (due to increased risk of dependence).

[8] Although haloperidol is used in UK clinical practice in the management of delirium tremens, at the time of publication (April 2017), it did not have a UK marketing authorisation for this indication. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information. In addition, the SPC advises caution in patients suffering from conditions predisposing to convulsions, such as alcohol withdrawal.

[9] Corticosteroids are used in UK clinical practice in the management of severe alcohol-related hepatitis. At the time of publication (April 2017), prednisolone did not have a UK marketing authorisation for this indication. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information.

[10] Maddrey's discriminant function (DF) was described to predict prognosis in alcohol-related hepatitis and identify patients suitable for treatment with steroids. It is 4.6 x [prothrombin time – control time (seconds)] + bilirubin in mg/dl. To calculate the DF using bilirubin in micromol/l divide the bilirubin value by 17.

  • National Institute for Health and Care Excellence (NICE)