Alcohol Withdrawal Syndrome

Criteria for Diagnosis

• Cessation or Reduction: Alcohol use that has been heavy and prolonged
• Symptoms: Two (or more) of the following within several hours to days after cessation:
  • Autonomic reactivity (e.g., sweating, HR > 100)
  • Increased hand tremor
  • Insomnia
  • Nausea or vomiting
  • Transient visual, tactile, or auditory hallucinations or illusions
  • Psychomotor agitation
  • Anxiety
  • Grand mal seizures
• Impact: Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
• Exclusions: Symptoms not due to a medical condition or another mental disorder
• Onset: 6-48 hours
• Duration: Average 2-10 days (may persist > 6 months)

Clinical Features

Stages of Withdrawal

• Stage I (6-24 hrs):
  • Anxiety
  • Restlessness
  • Decreased attention
  • Tremulousness
  • Insomnia
  • Craving
• Stage II (12-24 hrs):
  • Hallucinations (visual, auditory, tactile)
  • Misperceptions
  • Irritability
  • Vivid dreams
  • Confusion
  • Hypervigilance
• Stage III (24-48 hrs):
  • Generalized tonic-clonic seizures
• Stage IV (after 48-72 hrs):
  • Global confusional state
  • Autonomic hyperactivity
  • Tremors
  • Hallucinations
  • Seizures
  • Hyperadrenergic symptoms: diaphoresis, flushing, mydriasis, tachycardia, hypertension, low-grade fever
  • Note: Delirium Tremens (DTs) = delirium with tremor and autonomic overactivity; serious and life-threatening

Evaluation

History

• Pattern of drinking (daily vs. binge)
• Timing of last drink
• History of withdrawal symptoms with alcohol cessation
• Use AWS Scale/CIWA protocol

Examination

• Hydration status
• Mental status
• Encephalopathy, dementia
• Malnutrition
• Gastrointestinal issues (pancreatitis, gastritis, esophagitis, increased risk of GI bleeding)
• Cardiac issues (hypertension, cardiomyopathy)
• Chronic liver disease (ascites, jaundice, hepatic encephalopathy)
• Neurological disease (peripheral neuropathy, proximal myopathy, Wernicke-Korsakoff syndrome, cerebellar disease)

Labs

• Blood alcohol level
• Serum GGT (elevated in chronic drinkers)
• MCV (>96 fL)
• Abnormal liver function tests
• Carbohydrate-deficient transferrin
• HDL elevated, LDL lowered, serum uric acid elevated
• Electrolytes (Ca/Mg/Phos)
• CBC with differential, INR, PTT, liver function tests
• Urine drug screen (if concurrent toxidrome suspected)

Imaging

• Chest X-ray
• CT head (to exclude subdural hematoma if head injury suspected)

Withdrawal Assessment

• Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA)
• Alcohol Withdrawal Scale (AWS)

Outpatient or Inpatient detox and rehab: Suitability criteria for Outpatient therapy:

•  mild-moderate dependence (periodic drinker or low daily consumption)
•  no history of seizures or delirium tremens
•  no significant polydrug misuse
•  no benzodiazepine dependence
•  good social support
•  low suicide risk
• inpatient requires admission to private ward with close nursing supervision and monitoring

Management of Ambulatory Alcohol Withdrawal

Supportive Care

• Provide information about alcohol withdrawal to patients and carers
• Monitoring and supportive counseling from health workers (e.g., GP, drug and alcohol worker, nurse)
• Daily contact if possible
• 24-hour telephone counseling/crisis telephone service

Nutrition

• Plenty of fluids (at least 2 liters per day); light diet – avoid heavy meals
• Thiamine supplements: 300mg per day for 7 days; IM if nutritionally depleted, oral if healthy

Medication

• Oral Diazepam:
  • Drug of choice: Recommended for moderate to severe withdrawal
  • Long half-life (~100 hours)
  • Typical regimen:
    • Days 1 & 2: 10mg QID
    • Day 3: 10mg TDS
    • Day 4: 10mg BD
    • Day 5: 10mg nocte
  • Do not continue diazepam beyond 5 days
  • Limit access to diazepam (daily pickup or supervised by a responsible adult)
  • Withhold doses if patient continues to drink or is sedated

• Alternative: Lorazepam
  • Half-life: ~8-12 hours
  • Higher risk of withdrawal symptoms post-discharge due to shorter half-life
  • Consider if significant liver dysfunction is present

• Adjunct Symptomatic Medications:
  • Headache: paracetamol
  • Nausea and vomiting: metoclopramide
  • Abdominal cramps: hyoscine
  • Diarrhea: loperamide

• Medications Not Recommended:
  • Anticonvulsants, chlormethiazole, antipsychotics, and antidepressants

• Thiamine replacement:
  • Thiamine IV 300mg STAT
  • then 100mg daily 3/7
• Multidisciplinary team:
  • AOD, mental health, dietician, physical therapist
• Support: Alcoholic Anonymous, Online resources

https://www.racgp.org.au/your-practice/guidelines/drugs-of-dependence-b/2-evidence-based-guidance-for-benzodiazepines/24-alcohol-withdrawal

other neurological disorders associated with alcoholism

• Hepatic encephalopathy
• Wernicke encephalopathy
• SESA syndrome (subacute encephalopathy with seizures in alcoholics)
• Marchiafava-Bignami disease (demyelination of the corpus callosum)
• Osmotic demyelination syndrome (ODS)

Wernickes

• Complication of thiamine deficiency
• Ophthalmoplegia, ataxia, confusion
• Triad not always present
• Risk – hazardous alcohol, bariatric surgery, cancer, recurrent vomiting/diarrhoea
• Need immediate treatment to prevent Korsakoffs, coma, death
• Rx: 200-500mg IV TDS for 5-7 days – then down titrate

Hangover

A type of acute drug toxicity causing headache, nausea and fatigue.

Prevention

• Drink alcohol on a full stomach
• Select alcoholic drinks that suit you: avoid champagne
• Avoid fast drinking—keep it slow
• Restrict the quantity of alcohol
• Dilute your drinks
• Avoid or restrict smoking while drinking
• Drink three large glasses of water before retiring

Treatment

• Drink ample fluids especially water because of relative dehydration effect of alcohol
• Take two paracetamol tablets for headache.
• Drink orange juice or tomato juice, with added sugar.
• A drink of honey in lemon juice helps.
• Tea is a suitable beverage.
• Have a substantial meal but avoid fatty food.