What are the symptoms and management of alcohol withdrawal?

Symptoms and Management of Alcohol Withdrawal Syndrome

Benzodiazepines are the gold standard treatment for alcohol withdrawal syndrome, with short-acting benzodiazepines (lorazepam, oxazepam) preferred in patients with hepatic dysfunction and long-acting benzodiazepines (diazepam, chlordiazepoxide) preferred in patients with normal liver function. 1

Symptoms of Alcohol Withdrawal Syndrome

Alcohol withdrawal syndrome (AWS) typically begins 6-24 hours after the last drink and progresses through several stages:

Mild to Moderate Symptoms (6-24 hours after last drink):

• Increased blood pressure and pulse rate
• Tremors
• Hyperreflexia
• Irritability and anxiety
• Headache
• Nausea and vomiting
• Sweating 2, 3

Severe Symptoms (may develop if untreated):

• Seizures (typically within 24-48 hours)
• Hallucinations (visual, auditory, or tactile)
• Delirium tremens (characterized by altered mental status, disorientation, severe autonomic instability)
• Potentially fatal complications including cardiac arrest 2

Assessment of Withdrawal Severity

The Clinical Institute Withdrawal Assessment (CIWA) scale is recommended to assess AWS severity:

• Score ≤7: Mild withdrawal (monitor, may not require medication)
• Score 8-14: Moderate withdrawal (initiate benzodiazepine treatment)
• Score ≥15: Severe withdrawal (aggressive benzodiazepine treatment, consider inpatient management) 1

Treatment Setting Decision

Outpatient Management Appropriate for:

• Mild to moderate withdrawal symptoms
• No history of seizures or delirium tremens
• Adequate social support
• No significant comorbidities 1, 4

Inpatient Management Indicated for:

• Severe withdrawal symptoms
• History of withdrawal seizures or delirium tremens
• Significant comorbidities
• Failed outpatient treatment 1, 5

Pharmacological Management

First-Line Treatment:

• Benzodiazepines are the treatment of choice for AWS 2, 1, 6
  • For patients with normal liver function: Long-acting benzodiazepines (diazepam, chlordiazepoxide) provide better protection against seizures and delirium
  • For patients with hepatic dysfunction or elderly: Short-acting benzodiazepines (lorazepam, oxazepam) are safer 2, 1, 7

Alternative/Adjunctive Treatments:

• Carbamazepine or gabapentin may be used for mild symptoms or as adjuncts to benzodiazepines 1, 8
• Baclofen may be considered for patients with cirrhosis for maintenance of abstinence 1
• Avoid naltrexone and disulfiram due to hepatotoxicity in patients with liver disease 1

Thiamine Supplementation

Thiamine supplementation (100-300 mg/day) is essential to prevent Wernicke's encephalopathy:

• Must be administered before any glucose-containing solutions
• Should be continued for 2-3 months following resolution of withdrawal symptoms 1
• Intravenous administration is preferred for patients with poor nutritional status or severe complications 3

Monitoring and Follow-up

• Daily monitoring for up to five days after the last drink
• Assess for symptom improvement and need for additional treatment
• Regular liver function tests to track improvement
• Electrolyte panels to guide replacement therapy
• Clinical assessment of hydration status 1, 8

Complications Management

For Seizures:

• Oral benzodiazepines are the best-assessed treatment for withdrawal seizures 3

For Delirium Tremens:

• Aggressive benzodiazepine treatment
• Continuous monitoring of vital signs
• Fluid-electrolyte support
• Respiratory support if necessary 3, 5

With appropriate treatment, the mortality rate for delirium tremens is under 3%, but untreated or inadequately treated withdrawal can progress to life-threatening complications 3, 5.