From the Guidelines
Alcohol withdrawal typically starts within 6-24 hours after the last drink. For heavy drinkers, symptoms may begin as soon as blood alcohol levels start to decline, even before reaching zero. Early symptoms include anxiety, restlessness, nausea, and tremors. The withdrawal process generally progresses through three phases: mild symptoms (6-12 hours), moderate symptoms including increased heart rate and blood pressure (12-48 hours), and severe symptoms like seizures or delirium tremens (48-72 hours) 1. Withdrawal severity depends on drinking history, with longer and heavier use typically causing more intense symptoms.
Key Considerations
- Medical supervision is strongly recommended during alcohol withdrawal, as severe cases can be life-threatening.
- Treatment often includes benzodiazepines like diazepam or lorazepam, with dosing adjusted based on symptom severity 1.
- Thiamine is also typically administered to prevent Wernicke's encephalopathy, a serious neurological complication 1.
Symptoms and Treatment
- Symptoms of alcohol withdrawal syndrome (AWS) may include increased blood pressure and pulse rate, tremors, hyperreflexia, irritability, anxiety, headache, nausea, and vomiting 1.
- The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) is useful in clinical practice to assess the severity of AWS, with a score >8 indicating a moderate AWS and a score ≥15 indicating severe AWS 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.
From the Research
Alcohol Withdrawal Timeline
- Symptoms of alcohol withdrawal syndrome (AWS) may develop within 6-24 hours after the abrupt discontinuation or decrease of alcohol consumption 2.
- Alcohol withdrawal syndrome typically starts within 4-6 hours of the last alcohol use 3.
- Tremor, hallucinosis, and seizures usually occur within 48 hours of abstinence 4.
- Delirium tremens (DTs) usually appears after 48 hours of abstinence 4.
Factors Influencing Withdrawal Onset
- The main risk factors for severe withdrawal syndrome are chronic heavy drinking, a history of generalized seizures, and a history of delirium tremens 5.
- Anxiety, agitation, tremor, excessive sweating, altered consciousness, and hallucinations are signs of a severe withdrawal syndrome 5.
Treatment and Management
- Benzodiazepines are the gold-standard treatment for AWS and can be used to control mild early symptoms, prevent progression to DTs, or treat DTs itself 2, 4.
- Lorazepam and oxazepam are preferred agents for the management of AWS in patients with alcoholic liver disease (ALD) 3.
- Patients with mild or moderate alcohol withdrawal syndrome can be treated as outpatients, while those with severe symptoms or at high risk of complications should receive inpatient treatment 6.