What are the specific risk factors or findings that suggest Alcohol Withdrawal Syndrome (AWS) would be more likely?

From the Guidelines

Alcohol Withdrawal Syndrome (AWS) is more likely in patients with a history of heavy alcohol use, previous withdrawal episodes, and comorbid medical conditions, as well as those with clinical findings such as tremors, tachycardia, and elevated liver enzymes. The risk factors for AWS can be categorized into several key areas, including:

• History of heavy alcohol use (typically >8 drinks daily for men or >5 for women) and duration of alcohol use (years of regular consumption) 1
• Previous withdrawal episodes, which are a strong predictor of future withdrawal severity 1
• Comorbid medical conditions, such as cardiovascular disease, infections, or electrolyte abnormalities, which can increase the risk of complicated withdrawal 1
• Clinical findings, including:
  • Tremors, tachycardia, hypertension, diaphoresis, anxiety, and insomnia beginning 6-24 hours after the last drink 1
  • Elevated liver enzymes (AST, ALT, GGT), macrocytosis (elevated MCV), or an elevated blood alcohol level in someone who appears relatively functional 1
• The CIWA-Ar scale, which can help assess withdrawal severity, with scores above 8-10 indicating significant risk 1 It is essential to recognize these risk factors early, as AWS can progress rapidly and become life-threatening, with mortality rates for untreated delirium tremens reaching 5-15% 1. In terms of specific patient populations, female gender, obesity, and certain ethnicities (such as Hispanics) may be at higher risk for developing ALD and experiencing more severe withdrawal symptoms 1. Additionally, patients with a history of withdrawal seizures, delirium tremens, or co-occurring psychiatric illnesses are at higher risk for complicated withdrawal and may require more intensive treatment 1. Overall, a comprehensive assessment of these risk factors and clinical findings is crucial for identifying patients at high risk for AWS and providing appropriate treatment to prevent complications and improve outcomes.

From the Research

Risk Factors for Alcohol Withdrawal Syndrome (AWS)

The following are specific risk factors or findings that suggest AWS would be more likely:

• History of long-term, heavy alcohol consumption 2, 3
• Abrupt cessation or reduction of alcohol intake 3, 4
• Presence of two or more typical signs and symptoms of AWS, as defined by DSM-5 criteria 4
• High score on the Clinical Institute Withdrawal Assessment of Alcohol Scale, revised version (CIWA-Ar) 4
• Presence of additional risk factors for developing severe or complicated withdrawal, such as older age or pregnancy 2, 3

Assessment and Diagnosis

The following tools can be used to assess and diagnose AWS:

• The three-question Alcohol Use Disorders Identification Test-Consumption and the Single Alcohol Screening Question instrument to assess unhealthy alcohol use in adults 18 years and older 3
• The Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised, and the Short Alcohol Withdrawal Scale to assess withdrawal symptoms 3

Severity and Complications

The severity and potential complications of AWS can be significant, including:

• Generalized tonic-clonic seizures, delirium tremens, and death if left untreated or inadequately treated 3
• Life-threatening complications in its most severe form 2