From the Guidelines
Alcohol withdrawal can be fatal due to severe complications like delirium tremens, seizures, and autonomic instability, and medical treatment is essential to prevent these life-threatening symptoms. When someone who regularly consumes large amounts of alcohol suddenly stops drinking, their body, which has adapted to alcohol's depressant effects, experiences dangerous hyperactivity of the nervous system. This can lead to life-threatening symptoms including severe confusion, hallucinations, high fever, extreme hypertension, tachycardia, and grand mal seizures. The most dangerous period typically occurs 48-72 hours after the last drink, though risk extends up to 10 days.
Treatment of Alcohol Withdrawal
Medical treatment is essential and typically includes benzodiazepines like diazepam (5-10mg every 4-6 hours), lorazepam (2-4mg every 4-6 hours), or chlordiazepoxide (25-100mg every 4-6 hours), with dosing adjusted based on symptom severity, as recommended by the EASL clinical practice guidelines 1. Intravenous thiamine (100mg daily), adequate hydration, and electrolyte replacement are also crucial components of treatment.
Severity Assessment and Treatment Planning
The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) is useful in clinical practice for evaluating the severity of AWS and guiding treatment planning, with a score >8 indicating moderate AWS and a score ≥15 indicating severe AWS 1.
Importance of Medical Supervision
Without proper medical management, mortality rates for severe withdrawal with delirium tremens can reach 5-15% 1. Anyone with a history of heavy alcohol use should never attempt to quit drinking suddenly without medical supervision, as the withdrawal process requires careful monitoring and medication management to prevent potentially fatal complications. Psychiatric consultation is recommended for the evaluation, treatment, and long-term planning of alcohol abstinence, especially in cases with serious complications such as alcohol withdrawal delirium or seizures 1.
From the Research
Alcohol Withdrawal Syndrome
Alcohol withdrawal syndrome can range from mild to severe and may present with symptoms such as hallucinations, seizures, or delirium tremens 2. If left untreated or inadequately treated, withdrawal can progress to generalized tonic-clonic seizures, delirium tremens, and death 3.
Symptoms and Complications
The symptoms and complications of moderate to severe alcohol withdrawal can include:
- Autonomic hyperactivity
- Agitation
- Combativeness
- Hallucinations
- Seizures
- Delirium
- Death 4
Treatment and Management
Benzodiazepines are considered the gold standard for the treatment of alcohol withdrawal and have the largest and best evidence base 2. They can ameliorate or prevent the symptoms and complications of moderate to severe alcohol withdrawal. The benzodiazepines most commonly used for this purpose are lorazepam, chlordiazepoxide, oxazepam, and diazepam 4.
Benzodiazepine-Resistant Alcohol Withdrawal
Benzodiazepine-resistant alcohol withdrawal is a relatively new concept, and there is no single preferred definition 5. However, a high benzodiazepine dosage, seizures, and persistent tachycardia are main characteristics of resistant alcohol withdrawal. The median dose to describe high benzodiazepine dose is 40 mg per hour of diazepam equivalents 5.
Outpatient Management
Patients with mild to moderate withdrawal symptoms without additional risk factors for developing severe or complicated withdrawal should be treated as outpatients when possible 3. Ambulatory withdrawal treatment should include supportive care and pharmacotherapy as appropriate. Benzodiazepines are first-line therapy for moderate to severe symptoms, with carbamazepine and gabapentin as potential adjunctive or alternative therapies 3.