Substance use disorders
Alcohol withdrawal: timeline, scoring and benzodiazepine choice
When each stage appears, how symptom-triggered treatment works with the CIWA scale, which benzodiazepine fits which patient, and why thiamine comes before glucose.
8 min read·core·
Reviewed by a licensed nurse · 25 October 2026
Timeline after the last drink
| Time | Stage | Features |
|---|---|---|
| 6 to 24 hours | Minor withdrawal | Tremor, anxiety, sweating, nausea, insomnia, raised pulse and blood pressure |
| 12 to 48 hours | Withdrawal seizures | Generalized tonic-clonic seizures |
| 12 to 48 hours | Alcoholic hallucinosis | Hallucinations with a clear sensorium |
| 48 to 96 hours | Delirium tremens | Confusion, hallucinations, severe autonomic instability, fever. A medical emergency. |
Managing withdrawal
- 01
Assess severity and risk
Use the CIWA-Ar. Ask about prior seizures and delirium tremens, last drink and other substances. Check vital signs, electrolytes, glucose and magnesium.
- 02
Give a benzodiazepine
Symptom-triggered dosing is preferred in monitored settings. Long-acting drugs (diazepam, chlordiazepoxide) smooth the course. Lorazepam or oxazepam suit people with liver disease, the elderly and those at risk of oversedation.
- 03
Give thiamine
Give thiamine with or before glucose-containing fluids, and replace magnesium, phosphate and folate.
- 04
Escalate when needed
Resistant agitation needs ICU-level care. Phenobarbital or other adjuncts are options in specialist settings. Do not use antipsychotics alone.
Points to remember
- ·Delirium tremens carries a significant mortality if untreated.
- ·Gabapentin and carbamazepine are options for mild withdrawal in selected outpatients.
- ·Sedating the patient is not the goal: aim for calm but awake.
- ·After withdrawal, address relapse prevention (naltrexone, acamprosate, psychosocial treatment).
Check yourself
Did it stick?
1. A patient with cirrhosis is in alcohol withdrawal and needs a benzodiazepine. Which is the best choice?
2. Which sequence is correct for a malnourished patient in withdrawal who needs IV dextrose?
3. A patient is confused, hallucinating and febrile with a heart rate of 130 three days after stopping alcohol. What is the most likely diagnosis?
Sources
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Educational content for exam preparation. It is not clinical guidance and does not replace your facility's policies, current professional guidelines or the advice of a qualified clinician.