What are the signs and symptoms of alcohol withdrawal syndrome in a patient, such as Joanne, experiencing Alcohol Withdrawal (AW)?

From the Guidelines

Alcohol withdrawal symptoms typically begin within 6-24 hours after the last drink and can range from mild to severe, including anxiety, irritability, nausea, vomiting, tremors, sweating, headache, insomnia, and increased heart rate and blood pressure, with the most severe form being delirium tremens (DTs) which can be life-threatening 1. The signs and symptoms of alcohol withdrawal can be divided into several categories, including:

• Autonomic nervous system activation, such as tachycardia, sweating, and hand tremor
• Gastrointestinal symptoms, such as nausea and vomiting
• Deficits in cognitive function, such as hallucinations, seizures, and withdrawal delirium
• Other symptoms, such as fever, confusion, and agitation These symptoms can progress to more severe forms of AWS, characterized by delirium tremens, seizures, coma, cardiac arrest, and death 1. The severity of withdrawal depends on factors like how much and how long Joanne has been drinking, previous withdrawal experiences, and her overall health, and medical supervision is strongly recommended during alcohol withdrawal, as symptoms can rapidly worsen and become life-threatening 1. Treatment often includes medications like benzodiazepines (such as diazepam or lorazepam) to manage symptoms and prevent complications, with long-acting benzodiazepines providing more protection against seizures and delirium, but short and intermediate-acting benzodiazepines being safer in elderly patients and those with hepatic dysfunction 1. In addition to benzodiazepines, other medications such as baclofen and sodium oxybate have been tested in the treatment of AWS, and may have additional benefits in treating AUD 1. It is also important to note that thiamine deficiency is common in patients with alcohol use disorder, and thiamine should be given to all patients with AWS (100-300 mg/day) and maintained for 2-3 months following resolution of their withdrawal symptoms 1.

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 Protracted withdrawal syndrome associated with benzodiazepines is characterized by anxiety, cognitive impairment, depression, insomnia, formication, motor symptoms (e.g., weakness, tremor, muscle twitches), paresthesia, and tinnitus that persists beyond 4 to 6 weeks after initial benzodiazepine withdrawal.

The signs and symptoms of alcohol withdrawal are not directly addressed in the provided drug labels for lorazepam 2 and diazepam 3. However, delirium tremens is mentioned as a more severe acute withdrawal sign and symptom associated with benzodiazepines, which can also be a symptom of alcohol withdrawal.

• Common symptoms of alcohol withdrawal may include:
  • Anxiety
  • Depression
  • Fatigue
  • Headache
  • Hypertension
  • Irritability
  • Insomnia
  • Muscle pain and stiffness
  • Nausea and vomiting
  • Panic attacks
  • Restlessness
  • Tachycardia
  • Tremor
• More severe symptoms may include:
  • Catatonia
  • Convulsions
  • Delirium tremens
  • Hallucinations
  • Mania
  • Psychosis
  • Seizures
  • Suicidality

From the Research

Signs and Symptoms of Alcohol Withdrawal

The signs and symptoms of alcohol withdrawal can range from mild to severe and include:

• Mild symptoms: insomnia, tremulousness, anxiety, nausea, and vomiting 4, 5
• Moderate symptoms: irritability, agitation, tremors, diaphoresis, and hallucinations 6, 5
• Severe symptoms: delirium tremens, seizures, coma, and death 4, 7, 5

Timeline of Symptoms

Symptoms of alcohol withdrawal typically manifest within:

• 8 hours after alcohol cessation 5
• Reach their peak in 1-3 days 5
• Can extend for up to 2 weeks 5

Specific Symptoms and Their Timing

• Hallucinations: typically 12-24 hours after last alcohol intake 5
• Seizures: 12-48 hours after last intake 5
• Delirium tremens: approximately 72 hours after last alcohol intake 5

Management and Treatment

Management of alcohol withdrawal requires prompt recognition and control of symptoms, and may include:

• Administration of benzodiazepines 4, 7, 5
• Alternative medications such as barbiturates, ketamine, or propofol 5
• Intravenous hydration and benzodiazepines, phenobarbital, or alternative medications 5
• Treatment of hypoglycemia with concurrent administration of thiamine to prevent Wernicke's encephalopathy and subsequent Korsakoff syndrome 5