In a 28‑year‑old regular alcoholic man who develops tremor after drinking country liquor, what is the most likely diagnosis and appropriate acute management?

Acute Alcohol Withdrawal with Tremor in a 28-Year-Old Regular Drinker

This patient is experiencing acute alcohol withdrawal syndrome, and benzodiazepines are the mandatory first-line treatment—specifically, administer diazepam 10 mg orally every 3–4 hours or chlordiazepoxide 50–100 mg loading dose followed by 25–100 mg every 4–6 hours, combined with immediate thiamine 100–500 mg IV before any glucose administration. 1, 2, 3

Immediate Assessment (First 15 Minutes)

Critical first action: Administer thiamine 100–500 mg IV immediately before any glucose-containing fluids to prevent precipitating acute Wernicke encephalopathy in this chronic alcohol user. 1, 2

Vital Signs and Autonomic Assessment

• Check for autonomic instability: tachycardia, hypertension, fever, and diaphoresis—these indicate severity of withdrawal. 4, 1
• Measure blood pressure and pulse rate, which are typically elevated in early withdrawal (6–24 hours post-cessation). 4, 5
• Assess tremor severity (especially hand tremor), hyperreflexia, and level of agitation. 4, 1

Dangerous Complications to Rule Out

• Evaluate for hypoglycemia with finger-stick glucose (correct only after thiamine given). 1
• Assess for dehydration and check electrolytes, especially magnesium, which is commonly depleted. 1, 6
• Consider hepatic encephalopathy if underlying liver disease is suspected (asterixis-type tremor may be present). 1
• Rule out concurrent infection, gastrointestinal bleeding, or pancreatitis. 4, 1

Pharmacological Management

Benzodiazepine Therapy (Gold Standard)

Benzodiazepines are the only proven treatment that prevents seizures and reduces mortality from delirium tremens—no other medication class has this evidence. 1, 2, 6

For Patients WITHOUT Liver Disease:

• Diazepam 10 mg orally every 3–4 hours during the first 24 hours, or 1, 3
• Chlordiazepoxide 50–100 mg loading dose, then 25–100 mg every 4–6 hours (maximum 300 mg in first 24 hours). 2
• Long-acting benzodiazepines provide superior protection against seizures and delirium tremens compared to short-acting agents. 1, 2

For Patients WITH Suspected Liver Disease:

• Switch to lorazepam 2–4 mg orally every 4–6 hours (total 6–12 mg/day) because it has minimal hepatic metabolism and shorter half-life, avoiding drug accumulation. 1, 2
• Over 70% of cirrhotic patients may not require benzodiazepines at all; use symptom-triggered dosing rather than prophylactic administration. 1

Essential Adjunctive Treatment

• Thiamine 100–300 mg/day orally should be continued throughout withdrawal and for 2–3 months after resolution. 1, 2
• Aggressive fluid replacement with magnesium supplementation is essential, as magnesium is commonly depleted in chronic alcohol use. 1, 6
• Monitor and correct other electrolyte abnormalities (potassium, phosphate). 1

Medications to AVOID

• Do NOT use anticonvulsants alone for seizure prevention—benzodiazepines are required. 1, 2
• Avoid naltrexone in patients with alcoholic liver disease due to hepatotoxicity risk. 1
• Never administer glucose-containing IV fluids before thiamine, as this precipitates acute Wernicke encephalopathy. 1, 2

Timeline and Expected Course

• Tremors and autonomic symptoms begin 6–24 hours after last drink (this patient is in this window). 4, 1, 5
• Hallucinations may occur 12–24 hours after cessation in 2–8% of patients. 5, 6
• Seizures typically occur 12–48 hours after last intake in up to 15% of patients. 5, 6
• Delirium tremens peaks 48–72 hours after cessation and occurs in 3–5% of patients, with 15–50% mortality if untreated. 5, 6, 7, 8
• Symptoms generally peak at days 3–5 and resolve within one week. 1, 5

Inpatient vs. Outpatient Decision

Mandatory Inpatient Admission Criteria:

• Significant withdrawal symptoms with vomiting and tremor (this patient qualifies). 1
• History of withdrawal seizures or delirium tremens. 1
• Concurrent serious medical illness (liver disease, infection, pancreatitis, gastrointestinal bleeding). 1
• Psychiatric illness or suicide risk. 1
• Failure of prior outpatient treatment or insufficient social support. 1

Outpatient Management (Only for Mild Cases):

• Requires daily physician visits for 3–5 days to monitor vital signs and symptom severity. 1
• Patient must have reliable social support and no history of severe withdrawal. 1

Benzodiazepine Tapering Protocol

• Begin taper after approximately 96 hours (day 4) when acute symptoms are improving. 1
• Reduce daily dose by 25% every 2–3 days for long-acting agents (diazepam, chlordiazepoxide). 1
• Total benzodiazepine duration must not exceed 10–14 days to avoid iatrogenic dependence. 1, 2
• Monitor for rebound anxiety, tremor, or autonomic instability during dose reductions. 1

Post-Acute Management and Relapse Prevention

• Mandatory psychiatric consultation after stabilization to assess alcohol use disorder severity and plan long-term abstinence. 1, 2
• Relapse-prevention medications to consider after withdrawal completion:
  • Acamprosate (safe in liver disease, reduces craving). 1
  • Baclofen (only medication proven safe in cirrhosis). 1, 2
  • Disulfiram (avoid in severe liver disease). 1
  • Topiramate (shows promise for both withdrawal and relapse prevention). 2
• Encourage engagement with mutual-help groups such as Alcoholics Anonymous. 1

Critical Pitfalls to Avoid

• Never give glucose before thiamine—this can precipitate acute Wernicke encephalopathy. 1, 2
• Do not use anticonvulsants as monotherapy—benzodiazepines are the only proven seizure prevention. 1, 2
• Do not extend benzodiazepines beyond 14 days—this creates iatrogenic dependence requiring months-long taper. 1
• Do not use beta-blockers or antipsychotics as monotherapy—they do not prevent seizures or delirium tremens. 1
• Do not apply chronic benzodiazepine-dependence taper protocols to acute alcohol withdrawal—these are different conditions. 1

Severe Refractory Cases

If symptoms remain inadequately controlled despite adequate benzodiazepine dosing (rare, but may require very high doses up to 260–480 mg/day diazepam in severe cases): 9

• Consider adding phenobarbital or propofol as second-line sedative agents. 1
• Transfer to intensive care unit for continuous monitoring and mechanical ventilation if needed. 1, 7
• Dexmedetomidine may be added as adjunct only to reduce benzodiazepine requirements, but never as monotherapy. 1