Implementation of an Oral Ethanol Protocol for the Prevention and Management of Alcohol Withdrawal Syndrome

Jatinder Kaur, Nikhil Sarma, Darren Quelch, Arlene Copland, Carol Appleyard, Thomas Knight, Grace Williams, Sally Bradberry

Research output: Contribution to conferencePosterpeer-review


Aims, objectives and background
Conventional AWS management includes comprehensive assessment and monitoring by experienced practitioners, thiamine supplementation and pharmacological symptom management, usually with benzodiazepines. However, patients with high alcohol intake (typically ≥30units/24hours), often require escalating doses of benzodiazepines to effectively manage their AWS. Consequently, they are frequently too sedated for safe discharge. Moreover, they cannot engage in holistic assessments of their condition or recovery goals. The Alcohol Care Team (ACT) at Sandwell and West Birmingham Hospitals NHS Trust (SWBH) has introduced a protocol for the judicious use of oral ethanol in select cases, to reverse AWS symptoms and facilitate meaningful engagement. We present this protocol and initial experience of its implementation.

Method and design
Following assessment, standard thiamine provision and discussion with a consultant clinical toxicologist, oral ethanol is prescribed (handled as a controlled drug; source: ethanol 37.5%ABV (27ml/unit); diluted 1unit:50ml of fruit juice/squash; number of units prescribed based on patient history, clinical presentation and consultant acumen) for those presenting significant risk of severe physical withdrawal to alcohol with the aim of facilitating safe discharge from ED, or preventing development of delirium tremens. For those with contraindications (acute pancreatitis, haematemesis, nil-by-mouth, decompensated alcohol liver disease, severe alcoholic hepatitis), routine practice with benzodiazepines is followed. CIWA-Ar monitoring is performed hourly following administration, with consultant toxicologist review for scores ≥10 (see figure 1). When fit for discharge all patients are referred for follow-up by the SWBH ACT.

Results and conclusions
This protocol is now embedded at SWBH; 553 prescriptions of oral ethanol have been made since July 2019. Patient and staff experience has been overwhelmingly positive. The percentage of admissions whose primary diagnosis was AWS has reduced from 1.66% (2018) to 0.68% (2022). A detailed retrospective evaluation of 100 patients treated with oral ethanol is underway, assessing clinical and service level outcomes.
Original languageEnglish
Publication statusPublished - 26 Sept 2023
EventRoyal College of Emergency Medicine Annual Scientific Conference Glasgow 2023 - UK, Glasgow
Duration: 26 Sept 202328 Sept 2023


ConferenceRoyal College of Emergency Medicine Annual Scientific Conference Glasgow 2023


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