From the Guidelines
Alcohol withdrawal typically follows a predictable timeline, with symptoms beginning within 6-24 hours after the last drink and peaking around 72 hours, as noted in the 2018 EASL clinical practice guidelines 1. The timeline of alcohol withdrawal can vary in severity depending on the individual's drinking history. Symptoms usually begin within 6-12 hours after the last drink, starting with:
- Anxiety
- Restlessness
- Nausea
- Tremors From 12-24 hours, these symptoms intensify and may include:
- Increased heart rate
- Blood pressure
- Temperature The most severe phase occurs between 24-72 hours, when some individuals may experience:
- Hallucinations
- Seizures
- Delirium tremens (DTs), which is a medical emergency characterized by confusion, severe tremors, fever, and potentially life-threatening cardiovascular changes, as described in the 2013 KASL clinical practice guidelines 1. Benzodiazepines, such as diazepam or lorazepam, are recommended for the prevention of seizures and reduction of symptoms, with a symptom-triggered regimen rather than a fixed dose schedule, as stated in the 2018 EASL clinical practice guidelines 1. Most acute withdrawal symptoms peak around 72 hours and gradually improve over 5-7 days, though some psychological symptoms like anxiety, depression, and sleep disturbances may persist for weeks or months. Medical supervision is strongly recommended during alcohol withdrawal, as it is particularly dangerous for long-term heavy drinkers to attempt withdrawal without medical supervision. Thiamine (100mg daily), folate, and multivitamins are typically administered to prevent neurological complications, and adequate hydration and electrolyte replacement are also essential components of treatment, as noted in the 2013 KASL clinical practice guidelines 1.
From the Research
Alcohol Withdrawal Timeline
The alcohol withdrawal timeline can vary in severity and duration, but generally, symptoms resolve spontaneously within a week 2. However, more severe forms may be associated with generalized seizures, hallucinations, and delirium tremens, which can be fatal.
Symptoms and Timeline
- Tremor, hallucinosis, and seizures usually occur within 48 hours of abstinence 3
- Delirium tremens (DTs) usually appears after 48 hours of abstinence and consists of marked inattentiveness, agitation, hallucinations, fluctuating level of alertness, marked tremulousness, and sympathetic overactivity 3
- Symptoms can range from mild "hangover" to fatal delirium tremens (DTs) 3
Treatment and Management
- Benzodiazepines are the first-line treatment for alcohol withdrawal syndrome 2, 4, 5, 6
- Benzodiazepines can be used to control mild early symptoms, prevent progression to DTs, or treat DTs itself 3
- Supportive care, including hydration and vitamin supplementation, is also important in managing alcohol withdrawal 2, 5, 6
- Thiamine should be administered to all patients to prevent Wernicke-Korsakoff encephalopathy 5
Severe Withdrawal Syndrome
- Severe withdrawal syndrome can be predicted by risk factors such as chronic heavy drinking, history of generalized seizures, and history of delirium tremens 2
- Anxiety, agitation, tremor, excessive sweating, altered consciousness, and hallucinations are signs of a severe withdrawal syndrome 2
- Individual support and effective communication can reduce the risk of severe withdrawal syndrome 2