MD Notes

creation date: 2025-11-24 17:47
tags: Pathologies

Alcohol Withdrawal Syndrome

Background

Definitions

Alcohol withdrawal syndrome refers to a set of symptoms that may manifest following cessation of alcohol. The severity can range from mild to life-threatening.

The most severe manifestation of alcohol withdrawal is alcohol withdrawal delirium, formerly referred to as delirium tremens.

Etiology and risk factors

Chronic risky drinking and presence of alcohol use disorder increases the risk of alcohol withdrawal syndrome.

Alcohol withdrawal typically occur within 6-24 hours of last drink or a sudden reduction in chronic drinking and subside within 48 hours following cessation but alcohol withdrawal delirium can occur anywhere from 3-8 days following cessation.

Pathogenesis

The homeostasis of the CNS involves inhibitory signals from the GABAergic system balanced by the excitatory neurotransmitters (eg. glutamate).

Alcohol stimulates the GABAergic system, acting as a CNS depressant, which acutely manifests as disinhibition, euphoria, and sedation in a dose-dependent manner.

In chronic use, however, neuroadaptations result in an upregulation of glutamate and downregulation of endogenous GABA to compensate for persistent alcohol-related GABA activation.

When alcohol is withdrawal in this setting, a relative deficit in GABA occurs resulting in excitatory symptoms seen in alcohol withdrawal syndrome.

Clinical Presentation

Signs & Symptoms

Mild/early withdrawal:

  • Anxiety
  • Minor agitation
  • Restlessness
  • Insomnia
  • Tremor
  • Diaphoresis
  • Palpitations
  • Headache
  • Alcohol craving
  • Loss of appetite
  • Nausea/vomiting
  • Tachycardia and systolic hypertension
  • Hyperactive reflexes and tremour

Some patients may go on to develop additional manifestations:

  • Alcohol hallucinosis (visual usually, can be auditory or tactile) - 12-24 hours after last drink resolves after 24-48 hours; related to genetics and/or decreased thiamine absorption
  • Withdrawal seizures (generalized tonic-clonic convulsions); may occur due to concurrent benzodiazepine or other sedative withdrawal, low potassium and platelets

In the most severe form, withdrawal may progress to withdrawal delirium (delirium tremens). This is rapid-onset between 72-96 hours after last drink with:

  • Fluctuating disturbance of attention and cognition
  • Hallucinations
  • Agitation
  • Signs of autonomic hyperactivity (fever, severe tachycardia, hypertension, severe sweating)

History & Physical Exam

Key components of the history includes:

  • History of alcohol and drug use (incl. last use, duration of use, quantity, frequency, method)
  • History of withdrawal experiences and severity
  • Substance use treatment history
  • Mental health history
  • Social history (eg. homelessness, support structure)
  • Physical conditions that may worsen presentation/morbidity

A comprehensive physical exam should evaluate for:

  • Concurrent/alternative diagnoses
  • Chronic complications of alcohol use
  • Severity of withdrawal

Physical should include cardio-resp and GI systems. A neurological exam should be used to rule out Wernicke encephalopathy.

The Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) should be scored to guide treatment.

Diagnosis

Criteria

The DSM-T-TR criteria for alcohol withdrawal are:

  1. Cessation of (or reduction in) alcohol use that has been heavy and prolonged.
  2. Two (or more) of the following, developing within several hours to a few days after the cessation of (or reduction in) alcohol use described in criterion 1:
    • Autonomic hyperactivity
    • Increased hand tremor
    • Insomnia
    • Nausea or vomiting
    • Transient visual, tactile, or auditory hallucinations or illusions
    • Psychomotor agitation
    • Anxiety
    • Generalized tonic-clonic seizures
  3. The signs or symptoms in criterion 2 cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  4. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance.

Work-up

Laboratory studies

  • CBC
  • Serum electrolytes including potassium, magnesium, phosphate
  • Creatinine
  • Glucose
  • Liver function tests
  • Amylase and lipase
  • Blood alcohol level
  • Urine testing for other substances (especially opioids)
  • Urine hCG for premenopausal women

Imaging
A CT head is indicated for patients who present with a first seizure or for an atypical presentation compared to prior presentations to typical withdrawal seizures.

A chest radiograph may be used for patients with chronic respiratory problems, respiratory symptoms, or abnormal lung exam. Consider an abdominal ultrasound or CT if patient reports abdominal symptoms or pancreatic/liver tests are abnormal.

Additional work-up for alternative diagnoses
Extensive testing should be guided by clinical suspicion, especially in the presence of fever and/or altered mental status.

This may include:

  • Lumbar puncture
  • Cranial CT or MRI

Differential

While the diagnosis of alcohol withdrawal is often the leading consideration following a history of recent heavy alcohol use, a broad differential should be maintained in patients who are unable to give a reliable history or if comorbid conditions may exacerbate the presentation.

The differential includes:

  • Infections (eg. meningitis)
  • Acute coronary syndrome
  • Pulmonary embolism
  • Hyperthyroidism
  • Anxiety and/or panic disorder
  • Intoxication of stimulants
  • Withdrawal from other sedating substances (benzodiazepine withdrawal is virtually indistinguishable from alcohol without history)
  • Intracranial hemorrhage
  • Gastrointestinal bleeding

Red Flags / Complications

The primary complications are:

  • Wernicke encephalopathy (can be fatal)
  • Withdrawal seizure
  • Alcohol hallucinosis (and paranoia)
  • Alcohol withdrawal delirium, which can occur up to 3-5 days following cessation and can be fatal

Management

Management is indicated for a CIWA-Ar score >8.

Ambulatory Management

In patients with mild symptoms (CIWA-AR ≤15), no history of seizures of delirium tremens, and without complex cormobidities, supervised withdrawal can be managed in the ambulatory setting.

For patients with CIWA-Ar <10 (very mild), a fixed-dose gabapentin regime is used:

  • Day 1: 300 mg PO q6h
  • Day 2: 300 mg PO q8h
  • Day 3: 300 mg PO q12h
  • Day 4: 300 mg PO once daily at night

Extra tablets (5) of gabapentin are also given prn for symptom-triggered dosing.

For patients with CIWA-Ar 10-15 (mild), benzodiazepines are preferred for their well-documented effectiveness in reducing seizure and delirium. In the ambulatory setting, long-acting options are preferred.

Diazepam (Valium) 10 mg or chlordiazepoxide (Librium) 50 mg is used with the same tapering pattern as above. Similarly, 5 additional doses are given for symptoms.

Monitoring should be done daily with either in-person or remote visits. this includes:

  • Presence or worsening of withdrawal symptoms
  • Indications for need of higher level of care
  • Nutritional support if needed

Management of Moderate to Severe Withdrawal

For patients with CIWA-Ar score >15, in-patient management is indicated.

Supportive measures

Measures include:

  • IV fluids
  • Nutritional supplementation
  • Frequent reassessment (incl. vita signs)

Patients should be placed in quiet, protective environment. Mechanical restraints may be necessary temporarily for patients suffering from delirium tremens for protection of patient and providers but should be removed following chemical sedation.

In some settings, IV infusion of thiamine, folate, and a multivitamin in isotonic saline with 5% dextose (“banana bag” because of yellow appearance) is used but is not routinely recommended.

Patients may be kept NPO to prevent aspiration in early stages of alcohol withdrawal. Parenteral supplementation may be required to keep up with increased demand of excitatory state.

Treatment of psychomotor agitation

Benzodiazepines are used to treat the psychomotor agitation patients may experience.

Options include:

  • Diazepam (Valium) 5-10 mg IV q5-10 min until sufficiently sedated
  • Lorazepam (Ativan) 2-4 mg IV q15-20 min until sufficiently sedated
  • Chlordiazepoxide (Librium) IV

In younger patients without comorbidities, medication can be titrated to ensure safety and comfort while not obscuring neurologic examination. For older patients with pre-existing cardiopulmonary disease, however, heavier sedation front-loaded may be more beneficial.

In cases of refractory delirium tremens adjuvant phenobarbitol may be indicated but consultation should be made prior.

References

Tools / Guidelines

MDCalc - CIWA-Ar for Alcohol WIthdrawal

Additional Reading