What are the symptoms of alcohol withdrawal syndrome?

From the Guidelines

Benzodiazepines are the gold standard treatment for alcohol withdrawal syndrome (AWS), and should be used as the first-line treatment to reduce withdrawal symptoms and the risk of seizures and/or delirium tremens. Alcohol withdrawal symptoms can range from mild to severe and potentially life-threatening, typically beginning within 6-24 hours after the last drink and may include anxiety, tremors, sweating, nausea, vomiting, headache, insomnia, elevated heart rate, and blood pressure 1. In more severe cases, hallucinations, seizures, and delirium tremens (DTs) can occur, which is a medical emergency characterized by confusion, severe tremors, fever, and agitation.

Treatment Options

• Long-acting benzodiazepines (e.g. diazepam, chlordiazepoxide) provide more protection against seizures and delirium, but short and intermediate-acting benzodiazepines (e.g. lorazepam, oxazepam) are safer in elderly patients and those with hepatic dysfunction 1.
• The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) is a useful tool in clinical practice to assess the severity of AWS, with a score >8 indicating a moderate AWS and a score ≥15 indicating severe AWS 1.
• Other drugs, such as baclofen and sodium oxybate, have been tested in the treatment of AWS, but their use is not recommended as first-line treatment due to limited evidence and potential risks 1.

Management

• Withdrawal should be medically supervised, especially for heavy drinkers, as sudden cessation can be dangerous 1.
• Adequate hydration, nutritional support, and a quiet environment are also important components of withdrawal management.
• Thiamine (100mg daily) is essential to prevent Wernicke-Korsakoff syndrome, a potentially life-threatening complication of alcohol withdrawal 1.

Key Considerations

• Benzodiazepines and clomethiazole carry a potential risk of abuse, and their use should be limited to the initial 10-14 days of treatment 1.
• Topiramate and baclofen seem to be the most promising alternative treatments for AWS, but more research is needed to confirm their efficacy and safety 1.

From the FDA Drug Label

Among opioid free individuals, naltrexone hydrochloride administration at the recommended dose has not been associated with a predictable profile of serious adverse or untoward events However, as mentioned above, among individuals using opioids, naltrexone hydrochloride may cause serious withdrawal reactions A number of alternative dosing patterns have been recommended to try to reduce the frequency of these complaints Studies in alcoholic populations and in volunteers in clinical pharmacology studies have suggested that a small fraction of patients may experience an opioid withdrawal-like symptom complex consisting of tearfulness, mild nausea, abdominal cramps, restlessness, bone or joint pain, myalgia, and nasal symptoms

Naltrexone may cause alcohol withdrawal symptoms or an opioid withdrawal-like symptom complex in some patients, including tearfulness, mild nausea, abdominal cramps, restlessness, bone or joint pain, myalgia, and nasal symptoms 2.

From the Research

Alcohol Withdrawal Symptoms

• Alcohol withdrawal symptoms can range from mild to severe and include anxiety, tremors, diaphoresis, nausea, vomiting, hallucinations, seizures, and delirium tremens 3, 4, 5, 6, 7
• The symptoms typically manifest within eight hours after alcohol cessation, reach their peak in one to three days, and can extend for up to two weeks 7
• Delirium tremens is a potentially fatal encephalopathy that occurs in 3-5% of patients approximately 72 hours after last alcohol intake, and without recognition or prompt treatment, mortality can be as high as 50% 7

Diagnosis and Assessment

• The Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA-Ar), and the Short Alcohol Withdrawal Scale are commonly used tools to assess withdrawal symptoms 4, 6
• The Alcohol Use Disorders Identification Test-Consumption and the Single Alcohol Screening Question instrument have the best accuracy for assessing unhealthy alcohol use in adults 18 years and older 4

Treatment and Management

• Benzodiazepines are the first-line therapy for moderate to severe alcohol withdrawal symptoms, with carbamazepine and gabapentin as potential adjunctive or alternative therapies 3, 4, 5, 6, 7
• Supportive care, including hydration and vitamin supplementation, is also important in the management of alcohol withdrawal 4, 6, 7
• In severe cases, patients may require intensive care unit (ICU) admission and mechanical ventilation 7