From the Guidelines
The risk of withdrawal seizures typically ends within 1-2 weeks after the last drink, with most seizures occurring within the first 48-72 hours of alcohol cessation. This timeframe is supported by the most recent and highest quality study available, which emphasizes the importance of proper medical management during withdrawal to prevent complications such as seizures 1.
Key Factors Influencing Risk Duration
The risk duration varies based on individual factors including:
- The substance used
- Duration and amount of use
- Previous withdrawal history
- Underlying medical conditions
Mechanism of Withdrawal Seizures
Withdrawal seizures occur because chronic exposure to substances like alcohol or benzodiazepines downregulates inhibitory GABA receptors and upregulates excitatory NMDA receptors, creating a hyperexcitable state in the brain when the substance is removed 1. This neurochemical imbalance gradually normalizes as the brain readapts to functioning without the substance.
Management of Alcohol Withdrawal Syndrome
Proper medical management during withdrawal is essential, often involving medications like benzodiazepines (such as diazepam 5-10mg every 6 hours as needed, tapering over 3-10 days) for alcohol withdrawal, or a gradual taper of the original benzodiazepine for those dependent on these medications 1. Long-acting benzodiazepines are recommended for the prevention of seizures, with effects such as anxiety relief, sedation, and somnolence via activation of gamma-aminobutyric acid (GABA).
Additional Considerations
Diminished cognitive function due to thiamine deficiency is common in patients with alcohol use disorder; thiamine should thus be given to all patients with AWS (100-300 mg/day) and maintained for 2-3 months following resolution of their withdrawal symptoms 1. Psychiatric consultation is recommended for the evaluation and acute management of AWS and long-term abstinence planning.
From the FDA Drug Label
Dependence and Withdrawal Reactions To reduce the risk of withdrawal reactions, use a gradual taper to discontinue diazepam tablets or reduce the dosage (a patient-specific plan should be used to taper the dose) Acute Withdrawal Reactions The continued use of benzodiazepines, including diazepam tablets, may lead to clinically significant physical dependence Abrupt discontinuation or rapid dosage reduction of diazepam tablets after continued use, or administration of flumazenil (a benzodiazepine antagonist) may precipitate acute withdrawal reactions, which can be life-threatening (e.g., seizures) Protracted Withdrawal Syndrome In some cases, benzodiazepine users have developed a protracted withdrawal syndrome with withdrawal symptoms lasting weeks to more than 12 months
The risk of withdrawal seizure does not have a specified end time. Seizures can occur with abrupt discontinuation or rapid dosage reduction of diazepam tablets, and protracted withdrawal syndrome can last weeks to more than 12 months 2.
From the Research
Risk of Withdrawal Seizure
The risk of withdrawal seizure is a significant concern when discontinuing benzodiazepines or other substances. According to the available evidence:
- Withdrawal seizures can occur with short, medium, and long half-life benzodiazepines if discontinued abruptly 3.
- The risk of seizure is higher in patients who have been taking these medications for long periods of time and at high doses 3, 4.
- Seizures have also been reported with less than 15 days of use and at therapeutic dosage 3.
- The severity of seizures can range from a single episode to coma and death 3.
Time Frame for Withdrawal Seizure Risk
The time frame for the risk of withdrawal seizure is not strictly defined, but:
- Seizures can occur as early as 24 hours after the abrupt withdrawal of short-acting benzodiazepines 5.
- The peak incidence of seizures occurs 12-48 hours after the last oxazepam dose in patients undergoing alcohol withdrawal 6.
- The full-blown withdrawal syndrome, which can include seizures, usually lasts 10-14 days 4.
Factors Influencing Withdrawal Seizure Risk
Several factors can influence the risk of withdrawal seizure, including: