The Waco Guide

Yes
YesNo
typically 3-7 days
YesNo
No
YesNo
Yes
Yes
No
No
Yes
Yes
Alcohol withdrawal
Does patient meet
principal criteria for ambulatory
alcohol withdrawal?
Consider ambulatory
alcohol detoxification
Daily contact with patient;
daily CIWA
MVI + Thiamine
Gabapentin
SOR B
Reasonable option in
mild withdrawal
Equal to Benzodiazepines
in mitigating withdrawal
symptoms
Not shown to reduce risk of
delirium tremens
Benzodiazepine
SOR A
Does patient have
hepatic impairment?
LorazepamBenzodiazepine
Fixed dose regimen
generally recommended in
ambulatory setting
Ambulatory alcohol detoxification
successfully achieved?
See postwithdrawal
treatment
Determine etiology of failure;
consider retrial of above;
consider inpatient detox
Lorazepam
Chlordiazepoxide
Diazepam
Inpatient detox
Moderate to severe withdrawal
symptoms (CIWA ≥15)
Hx seizures or delirium tremens,
medical comorbidities
Ambulatory alcohol
withdrawal criteria
Mild withdrawal
symptoms (CIWA <15)
No prior history of
seizures or delirium tremens
Postwithdrawal treatment
12 step program
SOR A
Other options:
SMART, WFS, etc.
Pharmacotherapy
SOR A
Does patient have subgroup
indication/contraindication?
Hepatic impairment
(acute hepatitis, LFT ≥3x ULN,
liver failure)
Opioid use
Concurrent opioid use? Acamprosate
(avoid in CrCl <30)
Naltrexone
Abstinence
achieved?
Maintenance therapy;
continue minimum
1 year
Naltrexone trialed?
Trial Acamprosate
if no contraindications
Abstinence achieved?
Disulfiram
SOR B
Consider in highly motivated patients
with social support;
contraindicated in cardiac disease, psychosis,
ongoing alcohol use
Topiramate
SOR B
Caution in patients
taking Hydrochlorothiazide,
Metformin, Valproate
Acamprosate
trialed?
Trial Naltrexone
if no contraindications
No
Evaluate and treat
comorbid mood disorder
Alcohol Use Disorder

Is the patient currently using alcohol or experiencing withdrawal?