From the Guidelines
Alcohol withdrawal can be dangerous and potentially life-threatening, and it is crucial to seek medical help immediately if symptoms occur. Symptoms typically begin within 6-24 hours after the last drink and may include anxiety, irritability, nausea, vomiting, tremors (especially in the hands), sweating, increased heart rate, and insomnia 1. As withdrawal progresses, you might experience more severe symptoms like fever, confusion, hallucinations (seeing or hearing things that aren't there), and seizures. The most serious form, delirium tremens (DTs), usually occurs 2-3 days after stopping drinking and involves severe confusion, agitation, fever, seizures, and dangerous changes in blood pressure and heart rate.
Some key points to note about alcohol withdrawal symptoms include:
- Increased blood pressure and pulse rate
- Tremors
- Hyperreflexia
- Irritability
- Anxiety
- Headache
- Nausea
- Vomiting
- These symptoms may progress to more severe forms of AWS, characterized by delirium tremens, seizures, coma, cardiac arrest, and death 1.
Benzodiazepines are considered the 'gold standard' treatment for AWS, given their efficacy for reducing both withdrawal symptoms and the risk of seizures and/or delirium tremens. 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. It is essential to seek medical help if you experience withdrawal symptoms, as proper treatment significantly reduces complications and discomfort. Medical treatment typically involves medications like benzodiazepines (such as diazepam 5-10mg every 4-6 hours as needed), thiamine supplementation (100mg daily), and IV fluids.
In terms of management, the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) is useful in clinical practice, with a score >8 indicating a moderate AWS and a score ≥15 indicating severe AWS 1. Pharmacological treatment is recommended for both moderate and severe AWS using a symptom-triggered regimen rather than fixed dose schedule in order to prevent the accumulation of the drug. Other drugs, such as baclofen and sodium oxybate, have been tested in the treatment of AWS, and topiramate and baclofen seem the most promising 1.
From the Research
Signs and Symptoms of Alcohol Withdrawal
The signs and symptoms of alcohol withdrawal syndrome can range from mild to severe and include:
- Tremors
- Insomnia
- Nausea and vomiting
- Hallucinations
- Anxiety
- Agitation
- Mild to moderate tremors
- Irritability As stated in the study 2, approximately one-half of patients with alcohol use disorder who abruptly stop or reduce their alcohol use will develop signs or symptoms of alcohol withdrawal syndrome.
Severe Manifestations of Withdrawal
The most severe manifestations of withdrawal include:
- Delirium tremens
- Hallucinations
- Seizures
- Generalized tonic-clonic seizures According to the study 3, these manifestations result from alcohol-induced imbalances in the brain chemistry that cause excessive neuronal activity if the alcohol is withheld.
Assessment and Treatment of Withdrawal Symptoms
Two commonly used tools to assess withdrawal symptoms are the Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised, and the Short Alcohol Withdrawal Scale, as mentioned in the study 2. Treatment of alcohol withdrawal can include pharmacologic and nonpharmacologic approaches, such as:
- Benzodiazepines as first-line therapy for moderate to severe symptoms
- Carbamazepine or gabapentin as potential adjunctive or alternative therapies
- Supportive care As stated in the study 4, most patients undergoing alcohol withdrawal can be treated safely and effectively as outpatients. The study 5 also describes treatment protocols, including symptom-triggered versus fixed-schedule dosing of benzodiazepines.