From the Guidelines
Alcohol Withdrawal Syndrome (AWS) Symptoms and Treatment
Alcohol withdrawal is a potentially life-threatening condition that requires prompt medical attention. The symptoms of AWS typically develop within 6-24 hours after the last drink and may include increased blood pressure and pulse rate, tremors, hyperreflexia, irritability, anxiety, headache, nausea, and vomiting 1. If left untreated, these symptoms can progress to more severe forms of AWS, characterized by delirium tremens, seizures, coma, cardiac arrest, and death 1.
Treatment Options
Treatment typically involves the administration of benzodiazepines, such as diazepam (10-20 mg orally every 4-6 hours) or lorazepam (2-4 mg orally every 4-6 hours), to manage symptoms and prevent seizures 1. The duration of treatment is usually 3-7 days, with gradual tapering of the medication to minimize the risk of rebound withdrawal symptoms.
- Long-acting benzodiazepines (e.g., chlordiazepoxide and diazepam) are recommended for the prevention of seizures, with effects such as anxiety relief, sedation, and somnolence via activation of gamma-aminobutyric acid (GABA) 1.
- Lorazepam, which is an intermediate-acting benzodiazepine, is recommended for patients with severe AWS, advanced age, recent head trauma, liver failure, respiratory failure, other serious medical comorbidities, or obesity 1. Some key points to consider when treating AWS include:
- Using a symptom-triggered regimen rather than a fixed dose schedule to prevent the accumulation of the drug 1.
- Avoiding the use of benzodiazepines beyond the initial 10-14 days of treatment due to the potential risk of abuse 1.
- Administering thiamine (100-300 mg/day) to all patients with AWS to prevent Wernicke's encephalopathy and other nutritional deficiencies, and maintaining it for 2-3 months following resolution of their withdrawal symptoms 1.
- Considering the use of other medications, such as topiramate and baclofen, which have shown promise in treating AWS and preventing relapse 1.
From the FDA Drug Label
In acute alcohol withdrawal, diazepam may be useful in the symptomatic relief of acute agitation, tremor, impending or acute delirium tremens and hallucinosis The symptoms of Alcohol Withdrawal Syndrome (AWS) that can be relieved by diazepam include:
- Acute agitation
- Tremor
- Impending or acute delirium tremens
- Hallucinosis The treatment option for AWS mentioned in the label is diazepam, which can be used for the symptomatic relief of these symptoms 2
From the Research
Symptoms of Alcohol Withdrawal Syndrome (AWS)
- The symptoms of AWS can range from mild to severe and include anxiety, tremors, diaphoresis, nausea, and vomiting 3
- Severe symptoms can include hallucinations, seizures, and delirium tremens, which can be life-threatening if left untreated 4, 3
- The symptoms typically manifest within 8 hours after alcohol cessation, reach their peak in 1-3 days, and can extend for up to 2 weeks 3
Treatment Options for AWS
- Benzodiazepines are considered the gold standard for treating AWS, particularly for patients with severe symptoms 4, 5, 6
- Symptom-triggered benzodiazepine administration is a common approach, where the dose is adjusted based on the patient's symptoms 4, 6
- Alternative medications such as barbiturates, ketamine, or propofol may be used in patients who are resistant to benzodiazepines or have significant medical or psychiatric comorbidity 4, 5, 6
- Non-benzodiazepine GABAergic medications, such as carbamazepine, gabapentin, and valproic acid, have shown promise in treating AWS, but more research is needed to confirm their efficacy and safety 7
Management of AWS
- Early diagnosis and treatment are crucial to prevent complications and reduce the risk of mortality 4, 3, 6
- Patients with severe AWS may require hospitalization and close monitoring, particularly if they have significant medical or psychiatric comorbidity 4, 3, 6
- Outpatient management may be possible for patients with mild symptoms, but close follow-up is necessary to monitor for potential complications 4