Alcohol Withdrawal Syndrome

Background

• Alcohol withdrawal syndrome refers to a progression of signs and symptoms that occur following the reduction or cessation of alcohol intake after heavy and prolonged use.
• Symptoms typically occur in 4 clinical stages, but not all patients will experience all stages or progress sequentially through them:
  • minor withdrawal symptoms - stage 1
    • 6-12 hours after stopping alcohol
    • tremors, insomnia, irritability, mild agitation, anorexia, nausea, vomiting, tension, anxiety, sweating, restlessness
  • alcoholic withdrawal related hallucinations - stage 2
    • 12-24 hours after stopping alcohol
    • hallucinations (auditory, visual, or tactile) may occur
  • withdrawal seizures - stage 3
    • 24-48 hours after stopping alcohol, although may begin as early as 2 hours after stopping alcohol
    • usually tonic-clonic seizures
  • alcohol withdrawal delirium (delirium tremens) - stage 4
    • usually occurs 3-7 days after stopping alcohol but can occur at any time up to 14 days
    • hallucinations (usually visual), disorientation, tachycardia, hypertension, agitation, diaphoresis, low-grade fever
  • Consider prophylactic treatment in inpatients admitted for reasons other than alcohol withdrawal (and are without withdrawal symptoms) and who have history of withdrawal seizures, delirium tremens, or prolonged, heavy alcohol consumption.

Evaluation

• Diagnose alcohol withdrawal if stopping or decreasing heavy and prolonged alcohol use leads to typical symptoms in the absence of an alternative diagnosis.
• Evaluate for reasons leading to sudden reduction or cessation of alcohol intake, such as precipitating illness.
• Testing may include blood alcohol level, complete blood count, electrolyte levels, liver function tests, coagulation tests, urine and/or serum drug screen, and in selected patients lumbar puncture and neuroimaging for assessment of possible head trauma or other anatomic abnormalities of the central nervous system.
• Differential diagnosis is extensive, and 1 or more conditions may mimic or be associated with alcohol withdrawal.
• Assess for medical comorbidities and concomitant use of other addictive substances that may increase risk for complicated alcohol withdrawal.
• Consider using a tool such as the Clinical Institute Withdrawal Assessment-Alcohol, revised (CIWA-Ar) or another structured instrument to assess the initial severity of withdrawal and to monitor treatment.

Management

• Management involves alleviating symptoms and correcting metabolic abnormalities.
• Consider outpatient treatment for patients with mild-to-moderate symptoms who are not at high risk for delirium or withdrawal seizures and who have adequate recovery capital including social support and other resources.
• Admit all other patients for observation and treatment.
• Administer thiamine, and consider giving a multivitamin to patients with alcohol withdrawal.
• Do not administer magnesium routinely, but it should be given in patients with documented hypomagnesemia, electrolyte disturbances such as hypokalemia, cardiac arrhythmias, or a prior history of withdrawal seizures.
• Consider hydration, nutritional support, and electrolyte replacement as needed as part of the supportive care.
• Consider treatment with a benzodiazepine if CIWA-Ar score > 8-10.
  • Regimen options in the inpatient setting include symptom-triggered dosing, fixed-tapering dosing, or a loading-dose regimen. The symptom-triggered dosing is generally preferred in institutions capable of close patient monitoring.
  • Regimen options in the outpatient setting include fixed schedule or symptom-triggered schedule.
  • Symptom-triggered dosing shortens treatment duration and may reduce benzodiazepine use.
• Other medications may be used in certain situations:
  • Antiseizure medications, particularly carbamazepine, may be considered to treat seizures in patients with mild-to-moderate withdrawal.
  • Consider propofol for patients with resistant alcohol withdrawal requiring mechanical ventilation in intensive care unit.
  • Consider dexmedetomidine for patients with resistant alcohol withdrawal in intensive care unit.
  • Medications to consider in addition to benzodiazepine agent:
    • Consider using an adjunctive alpha2-adrenergic agonist in patients with persistent autonomic hyperactivity and anxiety despite benzodiazepine therapy.
    • Consider an adjunctive beta blocker in select patients with persistent hypertension or tachycardia despite benzodiazepine therapy.
    • Consider adjunctive antipsychotics if withdrawal delirium and hallucinations are not adequately controlled by benzodiazepine therapy alone.
    • In cases of severe alcohol withdrawal syndrome, phenobarbital alone or as an adjunct to benzodiazepines can be considered.
• After successful treatment of alcohol withdrawal syndrome, address alcohol use disorder in all patients. This may include:
  • Initiation of medications for alcohol use disorder;
  • Addressing underlying mental health needs;
  • Connecting patients to mutual support programs;
  • Referral to an addiction specialist, intensive outpatient programs, or inpatient rehabilitation programs for any patient with alcohol use disorder who is not reaching their goals regarding alcohol consumption.
  • See Alcohol Use Disorder for additional information.