What are the signs, symptoms, and management of alcohol withdrawal syndrome, including mild, moderate, and severe presentations, and potential dangers associated with it?

From the Guidelines

Joanne, if Thomas is experiencing moderate to severe alcohol withdrawal symptoms, you should seek immediate medical help by calling 911 or going to the emergency room—do not wait or try to manage it at home, as alcohol withdrawal can be life-threatening with a mortality rate of 1-5% even with treatment. Alcohol withdrawal symptoms occur when someone who regularly drinks heavily suddenly stops or reduces their alcohol intake. Mild symptoms typically appear within 6-12 hours after the last drink and include anxiety, insomnia, nausea, and tremors 1. Moderate symptoms usually develop 12-24 hours after stopping and may include increased blood pressure, confusion, mild fever, and pronounced tremors. Severe withdrawal, known as delirium tremens (DTs), can begin 48-72 hours after the last drink and includes hallucinations, severe confusion, seizures, high fever, and extreme agitation.

Some key points to consider:

• The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) is a useful tool in clinical practice to assess the severity of alcohol withdrawal syndrome, with a score >8 indicating moderate AWS and a score ≥15 indicating severe AWS 1.
• Benzodiazepines, such as diazepam or lorazepam, are considered the 'gold standard' treatment for AWS, given their efficacy in reducing both withdrawal symptoms and the risk of seizures and/or delirium tremens 1.
• Long-acting benzodiazepines provide more protection against seizures and delirium, but short and intermediate-acting benzodiazepines are safer in elderly patients and those with hepatic dysfunction 1.
• Other medications, such as baclofen and sodium oxybate, have been tested in the treatment of AWS, but their use is not as well established as benzodiazepines 1.

The potential dangers associated with alcohol withdrawal include:

• Seizures
• Delirium tremens
• Hallucinations
• Severe confusion
• High fever
• Extreme agitation
• Death

It is essential to seek medical help immediately if Thomas shows signs of moderate to severe withdrawal, as prompt treatment can help prevent complications and reduce the risk of mortality 1. Medical professionals can provide medications and supportive care to safely manage withdrawal symptoms and prevent complications like seizures or heart problems. Never attempt to detox someone with significant alcohol dependence without medical supervision.

From the FDA Drug Label

Acute withdrawal signs and symptoms associated with benzodiazepines have included abnormal involuntary movements, anxiety, blurred vision, depersonalization, depression, derealization, dizziness, fatigue, gastrointestinal adverse reactions (e.g., nausea, vomiting, diarrhea, weight loss, decreased appetite), headache, hyperacusis, hypertension, irritability, insomnia, memory impairment, muscle pain and stiffness, panic attacks, photophobia, restlessness, tachycardia, and tremor More severe acute withdrawal signs and symptoms, including life-threatening reactions, have included catatonia, convulsions, delirium tremens, depression, hallucinations, mania, psychosis, seizures, and suicidality

The signs and symptoms of alcohol withdrawal are not directly addressed in the provided drug labels. However, the labels do describe the signs and symptoms of benzodiazepine withdrawal, which can be similar to those of alcohol withdrawal.

• Mild symptoms may include anxiety, insomnia, and tremors.
• Moderate symptoms may include abnormal involuntary movements, blurred vision, depersonalization, depression, and gastrointestinal adverse reactions.
• Severe symptoms may include catatonia, convulsions, delirium tremens, hallucinations, mania, psychosis, seizures, and suicidality. If Joanne suspects that Thomas is experiencing moderate to severe alcohol withdrawal, she should seek immediate medical attention. The potential dangers associated with alcohol withdrawal include seizures, delirium tremens, and death 2 3.

From the Research

Signs and Symptoms of Alcohol Withdrawal

• The signs and symptoms of alcohol withdrawal can range from mild to severe and include tremors, sweating, hypertension, tachycardia, insomnia, nausea and vomiting, hallucinations, anxiety, and agitation 4.
• Delirium tremens is the most severe complication of alcohol withdrawal syndrome, characterized by clouded consciousness, disorientation, disturbed circadian rhythms, thought processes, and sensory disturbances, all of which can fluctuate in time 5.
• The severity of alcohol withdrawal symptoms can be assessed using tools such as the Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised, and the Short Alcohol Withdrawal Scale 4.

Timing of Alcohol Withdrawal Symptoms

• Mild alcohol withdrawal symptoms can occur within 6-24 hours after the last drink, while moderate symptoms can occur within 24-48 hours, and severe symptoms can occur within 48-72 hours 4.
• The timing and severity of symptoms can vary depending on individual factors, such as the amount and frequency of alcohol consumption, as well as the presence of underlying medical conditions.

Management of Moderate to Severe Alcohol Withdrawal

• If Joanne suspects that Thomas is experiencing moderate to severe alcohol withdrawal, she should seek medical attention immediately 5, 6, 7.
• Benzodiazepines, such as diazepam, lorazepam, and oxazepam, are considered the gold standard for treating moderate to severe alcohol withdrawal symptoms, due to their ability to ameliorate or prevent symptoms and complications 5, 6, 7.
• Supportive care, including the use of vitamins and monitoring of vital signs, is also essential in the management of alcohol withdrawal syndrome 5, 6, 8.

Potential Dangers Associated with Alcohol Withdrawal

• Untreated or inadequately treated alcohol withdrawal can progress to generalized tonic-clonic seizures, delirium tremens, and death 5, 4.
• Delirium tremens can result in death due to malignant arrhythmia, respiratory arrest, sepsis, severe electrolyte disturbance, or prolonged seizures and subsequent trauma 5.
• Alcohol withdrawal syndrome should be managed in a setting where vital signs can be monitored, such as an ICU or a ward with adequate medical supervision 5.