From the Guidelines
Alcohol withdrawal syndrome typically presents with symptoms such as tremors, anxiety, irritability, nausea, vomiting, headache, insomnia, and sweating, which can range from mild to severe, and in severe cases, can lead to delirium tremens, seizures, and potentially life-threatening complications. The signs of alcohol withdrawal syndrome can be categorized into mild, moderate, and severe symptoms. Mild symptoms include tremors, anxiety, irritability, nausea, vomiting, headache, and insomnia, while moderate symptoms include elevated heart rate, high blood pressure, fever, and sensory disturbances like tactile, auditory, or visual hallucinations. Severe symptoms, also known as delirium tremens (DTs), can develop 2-3 days after stopping drinking and include confusion, severe agitation, seizures, and potentially life-threatening cardiovascular events 1.
Symptoms and Signs
- Tremors, especially in the hands
- Anxiety
- Irritability
- Nausea
- Vomiting
- Headache
- Insomnia
- Sweating
- Elevated heart rate
- High blood pressure
- Fever
- Sensory disturbances like tactile, auditory, or visual hallucinations
- Delirium tremens (DTs), which includes confusion, severe agitation, seizures, and potentially life-threatening cardiovascular events
Diagnosis and Assessment
The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) is a useful tool for evaluating the severity of alcohol withdrawal syndrome, but it is not recommended for diagnosis due to its potential to yield high scores in psychiatric conditions similar to AWS, such as anxiolytic withdrawal, anxiety disorder, and physical conditions like sepsis, hepatic encephalopathy, and severe pain 1.
Treatment and Management
Benzodiazepines, such as diazepam or lorazepam, are the recommended treatment for alcohol withdrawal syndrome, with dosing adjusted based on symptom severity. Thiamine (100mg daily) is essential to prevent Wernicke's encephalopathy, and adequate hydration and electrolyte replacement are also crucial 1. In patients with decompensated liver disease, a personalized prescription that is symptom-adapted and favors short-acting drugs is recommended 1. Regular monitoring is necessary to guide dosage adjustment and ensure that there are no seizures.
Prevention of Complications
Medical supervision is strongly recommended during alcohol withdrawal due to potentially life-threatening complications. The use of benzodiazepines should be limited to the initial 10-14 days of treatment to avoid the risk of abuse, and other drugs like baclofen and sodium oxybate may be considered for their efficacy in treating AUD 1.
From the Research
Signs of Alcohol Withdrawal Syndrome
The signs of alcohol withdrawal syndrome can range from mild to severe and include:
- Anxiety, agitation, tremor, excessive sweating, altered consciousness, and hallucinations 2
- Tremors, insomnia, nausea and vomiting, hallucinations, anxiety, and agitation 3
- Clouded consciousness, disorientation, disturbed circadian rhythms, thought processes, and sensory disturbances 4
- Insomnia, tremors, and autonomic hyperactivity 5
- Tremor, hallucinosis, and seizures 6
Severe Signs of Alcohol Withdrawal Syndrome
Severe signs of alcohol withdrawal syndrome can include:
- Generalized seizures 2, 3, 6
- Delirium tremens, which can be fatal 2, 4, 6
- Marked inattentiveness, agitation, hallucinations, fluctuating level of alertness, marked tremulousness, and sympathetic overactivity 6
- Malignant arrhythmia, respiratory arrest, sepsis, severe electrolyte disturbance, or prolonged seizures and subsequent trauma 4
Diagnosis of Alcohol Withdrawal Syndrome
Diagnosis of alcohol withdrawal syndrome can be assessed using various tools, including:
- Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA-Ar) 5
- Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised, and the Short Alcohol Withdrawal Scale 3
- The three-question Alcohol Use Disorders Identification Test-Consumption and the Single Alcohol Screening Question instrument 3