When does an alcoholic typically experience withdrawal and delirium tremens (DTs) after their last drink?

Timeline of Alcohol Withdrawal and Delirium Tremens

Alcohol withdrawal symptoms begin within 6-24 hours after the last drink, with delirium tremens (DTs) typically starting 48-72 hours after cessation and peaking at days 3-5. 1, 2

Early Withdrawal Phase (6-24 Hours)

Light to moderate withdrawal symptoms develop first within 6-24 hours after the last drink, including: 1, 2

• Autonomic nervous system activation (increased blood pressure and pulse rate) 1
• Tremors and hyperreflexia 1
• Irritability and anxiety 1
• Headache, nausea, and vomiting 1
• Sweating and hand tremor 1, 2

This is the critical window to initiate benzodiazepine treatment to prevent progression to severe complications. 2 Long-acting benzodiazepines like diazepam or chlordiazepoxide provide superior protection against seizures and delirium tremens compared to shorter-acting agents. 1, 3

Intermediate Phase (Within 48 Hours)

Withdrawal seizures typically occur within the first 48 hours as a rebound phenomenon due to lowered seizure threshold. 2, 4 These are generalized seizures without focality, occurring singly or in brief clusters. 4 Importantly, these do not require anticonvulsants—only benzodiazepines. 1, 2

Severe Phase: Delirium Tremens (48-72 Hours to Day 5)

Delirium tremens represents the most severe manifestation, typically beginning 48-72 hours after the last drink with peak severity at days 3-5. 1, 2, 4 DTs are characterized by: 1, 2

• Altered mental status and disorientation to person, place, or time 1
• Hallucinations (visual, auditory, or tactile) 1, 4
• Marked agitation and confusion 4, 5
• Severe autonomic hyperactivity (high fever, tachycardia, hypertension, profuse sweating) 1, 4
• Marked tremulousness 4
• Fluctuating level of alertness throughout the day 1, 4

Without prompt treatment, DTs can progress to seizures, coma, cardiac arrest, and death. 1 The mortality rate for untreated DTs remains significant, but with appropriate benzodiazepine therapy, fluid-electrolyte support, and continuous monitoring, mortality can be reduced to under 3%. 6

Critical Treatment Timing

Benzodiazepines should be initiated early (within 6-24 hours) to prevent progression, not just to treat established severe withdrawal. 2 For severe AWS with altered consciousness, intravenous diazepam 10 mg initially, followed by 5-10 mg every 3-4 hours as needed, is recommended. 3

Thiamine 100-500 mg IV must be administered immediately before any glucose-containing fluids to prevent Wernicke encephalopathy. 3, 2 This is a medical emergency that can develop if thiamine is not adequately supplemented during the withdrawal period. 3

Resolution Timeline

Symptoms generally resolve spontaneously within one week, with most patients showing improvement by 96 hours and nearing resolution of acute withdrawal. 3, 6 However, symptoms starting 6 days or more after cessation are well beyond the expected window for alcohol withdrawal and suggest an alternative diagnosis such as Wernicke encephalopathy or hepatic encephalopathy. 3

Common Pitfalls to Avoid

• Never administer glucose-containing IV fluids before thiamine, as this can precipitate acute Wernicke encephalopathy. 3
• Do not use anticonvulsants for alcohol withdrawal seizures—these are rebound phenomena requiring benzodiazepines only. 1, 2
• Do not continue benzodiazepines beyond 10-14 days due to abuse potential. 3
• In patients with hepatic dysfunction or elderly patients, switch to lorazepam or oxazepam rather than long-acting agents. 1, 3

Monitoring Requirements

Continuous monitoring of vital signs is crucial for autonomic instability, with careful assessment for complications including dehydration, electrolyte imbalance (especially magnesium), infection, gastrointestinal bleeding, pancreatitis, hepatic encephalopathy, and renal failure. 1, 3 Patients should be monitored daily for up to 5 days after their last drink to verify symptom improvement. 3