From the Guidelines
Yes, there is still concern for ethanol withdrawal two days after the last drink. According to the most recent and highest quality study, alcohol withdrawal symptoms typically begin 6-24 hours after the last drink, peak at 24-72 hours, and can last up to 7-10 days in some cases 1. The most severe symptoms, including seizures and delirium tremens (DTs), often emerge 48-72 hours after cessation, making the two-day mark a particularly critical period.
Key Considerations
- Treatment typically involves benzodiazepines, with short-acting benzodiazepines like lorazepam or oxazepam preferred in patients with hepatic insufficiency to avoid drug accumulation 1.
- The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale can help monitor withdrawal severity and guide medication dosing 1.
- Supportive care including IV fluids, thiamine (100mg daily), folate, and multivitamins is also important to prevent complications like Wernicke's encephalopathy 1.
- Patients should be monitored for complications such as seizures, hallucinations, and cardiovascular instability, with regular monitoring stopping after 24 hours if no specific signs appear 1.
Treatment Approach
- Benzodiazepines are the gold standard treatment for alcohol withdrawal syndrome, given their efficacy in reducing withdrawal symptoms and the risk of seizures and/or delirium tremens 1.
- The choice of benzodiazepine and dosage should be personalized, taking into account the patient's symptoms, liver function, and risk of abuse 1.
- Thiamine should be prescribed as part of the withdrawal process to prevent Wernicke's encephalopathy, given the high prevalence of thiamine deficiency in alcohol-dependent individuals 1.
From the Research
Ethanol Withdrawal Concerns
- There is still concern for ethanol (etoh) withdrawal two days after the last drink, as the symptoms of alcohol withdrawal syndrome can last for several days 2.
- The symptoms of alcohol withdrawal syndrome generally resolve spontaneously within a week, but more severe forms may be associated with generalized seizures, hallucinations, and delirium tremens, which can be fatal 2.
- The risk of severe withdrawal syndrome is higher in patients with a history of chronic heavy drinking, generalized seizures, and delirium tremens 2.
Timeline of Withdrawal Symptoms
- Alcohol withdrawal syndrome begins six to 24 hours after the last intake of alcohol, and the signs and symptoms include tremors, agitation, nausea, sweating, vomiting, hallucinations, insomnia, tachycardia, hypertension, delirium, and seizures 3.
- The symptoms can peak between 24 to 72 hours after the last drink, and can last for several days 2, 3.
Management of Withdrawal Symptoms
- Patients with mild or moderate alcohol withdrawal syndrome can be treated as outpatients, while those with severe symptoms or who are at high risk of complications should receive inpatient treatment 3.
- Benzodiazepines are recommended for the treatment of alcohol withdrawal syndrome, and should be given at the onset of symptoms and continued until symptoms subside 2, 3.
- Other medications, such as carbamazepine, oxcarbazepine, valproic acid, and gabapentin, may also be used, but have less evidence to support their use 3.