Alcohol Withdrawal Timeline
Alcohol withdrawal symptoms typically begin 6-24 hours after the last drink, peak at 1-3 days, and can persist for up to 2 weeks, with the most dangerous complication—delirium tremens—occurring around 72 hours after cessation. 1, 2, 3
Early Phase (6-24 Hours)
Mild to moderate symptoms emerge within the first 6-24 hours and include: 1, 2, 3
- Tremors (most common early sign) 1, 2
- Autonomic hyperactivity: increased blood pressure, tachycardia, diaphoresis 1, 3
- Anxiety, agitation, and irritability 1, 2
- Nausea and vomiting 1, 2
- Headache and hyperreflexia 1
- Insomnia 2, 3
Intermediate Phase (12-48 Hours)
Hallucinations and seizures typically occur during this window: 2, 3
- Hallucinations develop in 2-8% of patients, usually 12-24 hours after last intake 3
- Alcohol withdrawal seizures occur in up to 15% of patients, typically 12-48 hours after cessation 3, 4
- Seizures are generalized tonic-clonic in nature 5
- Continued autonomic instability with worsening tremors and agitation 4
Peak Severity (24-72 Hours)
Symptoms reach maximum intensity at 1-3 days after the last drink: 2, 3
- Most severe autonomic symptoms occur during this period 3
- Delirium tremens (DTs) develops in 3-5% of patients, approximately 72 hours after last alcohol intake 3
- DTs presents with severe encephalopathy, profound confusion, disorientation, and marked autonomic dysfunction 3
- Without treatment, mortality from delirium tremens can reach 50%; with appropriate treatment, mortality is under 3% 5, 3
Resolution Phase (5-14 Days)
Symptoms generally resolve spontaneously within one week, though some may persist up to two weeks: 2, 5, 3
- Most patients experience symptom resolution by day 5-7 5, 6
- Residual symptoms (anxiety, insomnia, mild tremor) may continue for up to 2 weeks 3
- Physicians should monitor outpatients daily for up to 5 days after the last drink to verify symptom improvement 6
Critical Risk Factors for Severe Withdrawal
The following predict higher risk of complicated withdrawal requiring inpatient management: 5
- History of delirium tremens 5
- History of alcohol withdrawal seizures 5
- Chronic heavy drinking pattern 5
- Concurrent serious medical or psychiatric disorders 7
- Inadequate social support 7
Essential Treatment Considerations
Benzodiazepines remain the gold standard and should be initiated at symptom onset: 1, 7
- Long-acting benzodiazepines (diazepam, chlordiazepoxide) provide better seizure protection 1, 7
- Short-acting agents (lorazepam, oxazepam) are safer in elderly patients and those with hepatic dysfunction 1
- Treatment duration should be limited to 10-14 days to prevent iatrogenic dependence 7, 8
Thiamine administration is mandatory for all patients to prevent Wernicke's encephalopathy: 1, 7, 8