From the Guidelines
Alcohol withdrawal symptoms typically peak within 24 to 72 hours after the last drink, with the most severe symptoms, including hallucinations, seizures, and delirium tremens, generally occurring during this period. According to the most recent and highest quality study 1, alcohol withdrawal syndrome (AWS) is a severe medical condition affecting alcohol-dependent patients who suddenly discontinue or decrease alcohol consumption. The study notes that light or moderate AWS usually develops within 6–24 h after the last drink, with symptoms progressing to more severe forms of AWS, characterized by delirium tremens, seizures, coma, cardiac arrest, and death.
Key Points to Consider
- The severity of withdrawal correlates with the duration and amount of alcohol consumption, with long-term heavy drinkers experiencing more intense symptoms 1.
- Medical supervision is strongly recommended during alcohol withdrawal, as healthcare providers can administer medications like benzodiazepines (such as diazepam, chlordiazepoxide, or lorazepam) to manage symptoms and prevent complications 1.
- Benzodiazepines are considered the ‘gold standard’ treatment for AWS, given their efficacy for reducing both withdrawal symptoms and the risk of seizures and/or delirium tremens 1.
- The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) is useful in clinical practice, with a score >8 indicating a moderate AWS and a score ≥15 indicating severe AWS 1.
Treatment and Management
- Pharmacological treatment is recommended for both moderate and severe AWS using a symptom-triggered regimen rather than fixed dose schedule in order to prevent the accumulation of the drug 1.
- Long-acting benzodiazepines (e.g. diazepam, chlordiazepoxide) provide more protection against seizures and delirium, but short and intermediate-acting benzodiazepines (e.g. lorazepam, oxazepam) are safer in elderly patients and those with hepatic dysfunction 1.
From the Research
Alcohol Withdrawal Peak
- Symptoms of alcohol withdrawal typically manifest within 8 hours after alcohol cessation, reach their peak in 1 to 3 days, and can extend for up to two weeks 2.
- Delirium tremens, a potentially fatal encephalopathy, usually appears after 48 hours of abstinence and consists of marked inattentiveness, agitation, hallucinations, fluctuating level of alertness, marked tremulousness, and sympathetic overactivity 3, 4.
- Seizures tend to occur within 48 hours of abstinence, while hallucinations typically occur 12-24 hours after last alcohol intake 3, 2.
- The peak of alcohol withdrawal symptoms can vary depending on the individual and the severity of their alcohol use disorder.
Factors Influencing Withdrawal Peak
- The severity of alcohol withdrawal symptoms can be influenced by factors such as the amount and duration of alcohol use, as well as the presence of underlying medical conditions 5, 6.
- The use of benzodiazepines and other medications can also impact the peak of alcohol withdrawal symptoms, as they can help to reduce the severity of symptoms and prevent complications such as seizures and delirium tremens 3, 5, 4, 6, 2.
Treatment and Management
- The treatment of alcohol withdrawal typically involves the use of benzodiazepines, such as diazepam or lorazepam, to reduce the severity of symptoms and prevent complications 3, 5, 4, 6, 2.
- Other medications, such as barbiturates, ketamine, or propofol, may also be used in certain cases, particularly for patients who are refractory to benzodiazepines or who have severe symptoms 5, 2.
- Supportive care, such as hydration and electrolyte replacement, is also important in the management of alcohol withdrawal 3, 4, 6, 2.