From the Guidelines
Delirium tremens (DTs) typically develop within 48 to 96 hours after the last drink in individuals undergoing alcohol withdrawal, with the peak incidence occurring around 72 hours 1.
Key Points
- The symptoms of DTs are typically worst at 3-5 days following the abrupt cessation of alcohol consumption 1.
- Benzodiazepines are considered the ‘gold standard’ treatment for AWS, given their efficacy to reduce both withdrawal symptoms and the risk of seizures and/or delirium tremens 1.
- Administration of benzodiazepines, such as diazepam 10-20 mg every 4-6 hours, or lorazepam 2-4 mg every 4-6 hours, can help prevent or mitigate the development of DTs.
- It is recommended to use short half-life benzodiazepines in cirrhotic patients (oxazepam or lorazepam) to avoid drug accumulation in patients who are otherwise at risk of developing encephalopathy 1.
- Thiamine should be given to all patients with AWS to prevent the onset of Wernicke's encephalopathy, with a recommended dose of 100-300 mg/day 1.
Important Considerations
- The presence of a decompensated liver disease must encourage prioritisation of a personalised prescription that is symptom adapted and favours short-acting drugs 1.
- Patients at risk of severe withdrawal, or who have concurrent serious physical or psychiatric disorders, or who lack adequate support, should preferably be managed in an inpatient setting 1.
From the Research
Delirium Tremens (DTs) Development Timeline
The timeline for Delirium Tremens (DTs) development after alcohol (ethanol) withdrawal is as follows:
- DTs usually appear within 48-72 hours of abstinence 2, 3
- Symptoms can persist for about 5-10 days 2
- In some cases, DTs can have a delayed onset, occurring as late as 15 days after the cessation of alcohol use 2
- Tremor, hallucinosis, and seizures usually occur within 48 hours of abstinence, while DTs typically appear after 48 hours of abstinence 3
Factors Influencing DTs Development
Several factors can influence the development of DTs, including:
- Severity of alcohol withdrawal 4
- Presence of underlying medical co-morbidities, such as liver disease 4
- Low platelet count, high blood level of homocysteine, and low blood level of pyridoxine 5
- History of alcohol withdrawal seizures 5
Treatment and Management
Treatment and management of DTs typically involve:
- Benzodiazepine pharmacotherapy, such as diazepam and lorazepam 6, 4, 3
- Heavy sedation in an intensive care unit, with close attention to autonomic instability, fever, fluid loss, and electrolyte imbalance 3
- Alternative pharmacotherapies, such as phenobarbital, anticonvulsants, and alpha-2-agonists, may be used in benzodiazepine refractory cases 4, 3