Overview #
- Alcohol withdrawal is a clinical diagnosis referring to the constellation of symptoms that occurs with chronic alcohol use after an abrupt decrease or cessation of alcohol intake
- Can occur within 6 – 24 hours from an individual’s last drink (1)
- Symptoms typically resolve within 72 hours but may persist for weeks (1)
- Can be life-threatening if severe (eg – seizures, delirium tremens) (2)
- Explore history of dependence and previous alcohol withdrawal
- Does not occur in non-dependent individuals consider other differentials for similar presentation of symptoms (3)
- Significant withdrawal likely with chronic alcoholic intake (at least 2 weeks duration) of ≥8 SD in men and ≥6 SD in women (3)
Severity scales are useful in assessing and monitoring the severity of alcohol withdrawal. However, lower scores do not exclude the diagnosis. Similarly, higher scores are not diagnostic (4)
References #
1. Topic | Therapeutic Guidelines [Internet]. [cited 2021 Aug 30]. Available from: https://tgldcdp-tg-org-au.eu1.proxy.openathens.net/viewTopic?topicfile=alcohol-drug-problems#toc_d1e103
2. Management of moderate and severe alcohol withdrawal syndromes – UpToDate [Internet]. [cited 2021 Aug 30]. Available from: https://www.uptodate.com/contents/management-of-moderate-and-severe-alcohol-withdrawal-syndromes?search=alcohol%20withdrawal&topicRef=108527&source=see_link
3. Alcohol withdrawal management | SA Health [Internet]. [cited 2021 Aug 30]. Available from: https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/clinical+resources/clinical+programs+and+practice+guidelines/substance+misuse+and+dependence/substance+withdrawal+management/alcohol+withdrawal+management
4. CIWA-Ar for Alcohol Withdrawal – MDCalc [Internet]. [cited 2021 Aug 31]. Available from: https://www.mdcalc.com/ciwa-ar-alcohol-withdrawal
5. Alcohol withdrawal: Epidemiology, clinical manifestations, course, assessment, and diagnosis – UpToDate [Internet]. [cited 2021 Aug 30]. Available from: https://www.uptodate.com/contents/alcohol-withdrawal-epidemiology-clinical-manifestations-course-assessment-and-diagnosis?search=alcohol%20withdrawal&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#H1641691707
6. Alcohol withdrawal – Knowledge @ AMBOSS [Internet]. [cited 2021 Aug 30]. Available from: https://www.amboss.com/us/knowledge/Alcohol_withdrawal/
7. Alcohol withdrawal – Australian Medicines Handbook [Internet]. [cited 2021 Aug 31]. Available from: https://amhonline-amh-net-au.eu1.proxy.openathens.net/chapters/psychotropic-drugs/drugs-alcohol-dependence/alcohol-withdrawal
8. Topic | Therapeutic Guidelines [Internet]. [cited 2021 Aug 31]. Available from: https://tgldcdp-tg-org-au.eu1.proxy.openathens.net/viewTopic?topicfile=vitamin-mineral-deficencies§ionId=gig-c16-s3#gig-c16-s3-2
9. Schizophrenia Spectrum and Other Psychotic Disorders. In: Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association; 2013.
10. Diazepam – Australian Medicines Handbook [Internet]. [cited 2021 Aug 30]. Available from: https://amhonline-amh-net-au.eu1.proxy.openathens.net/chapters/psychotropic-drugs/drugs-anxiety-sleep-disorders/benzodiazepines/diazepam#diazepam-benzodiazepines-precautions
11. Prediction of Alcohol Withdrawal Severity Scale – MDCalc [Internet]. [cited 2021 Aug 30]. Available from: https://www.mdcalc.com/prediction-alcohol-withdrawal-severity-scale#evidence12. Medline ® Abstracts for References 3,26,27 of “Management of moderate and severe alcohol withdrawal syndromes” – UpToDate [Internet]. [cited 2021 Aug 31]. Available from: https://www.uptodate.com/contents/management-of-moderate-and-severe-alcohol-withdrawal-syndromes/abstract/3,26,27
Triage #
- Severe withdrawal (seizures, hallucinations or delirium tremens) = emergency requiring immediate attention
- Moderate symptoms or high risk of withdrawal = attend within 1 hour
- Mild symptoms = attend within hours
Causes #
Precipitants
- Cessation or reduction of alcohol drinking – eg – hospital admission
Differentials
Include differentials to altered conscious state:Acute drop in GCS and psychiatric illnesses (eg – anxiety disorders, psychosis)
Clinical features #
Red flags
| Patient factors | Medical factors |
| Age ≥65 (6)≥8SD/day in men; ≥6SD/day in women for ≥2 weeks (6)Concurrent substance useSocial circumstances – poor social networks, homelessness, etc (6) | Significant medical and/or psychiatric comorbidities (6)History of withdrawal seizures, hallucinations or delirium tremens (2,6)Current seizures, hallucinations or delirium tremens (2,6) |
History
- Drug and alcohol
- Substance use
- Medications – benzodiazepines (BZ), opioids, anti-convulsants
- Time of last drink
- Signs of dependence – CAGE questionnaire
- Collateral may be useful for accurate consumption estimate
- Withdrawal symptoms
| Severity | Mild | Severe |
| Symptoms | GI – Nausea, vomiting CNS – tremor, headache, visual changesMental state – mild anxiety & agitation Other – insomnia, diaphoresis, palpitations | Seizures – generalized tonic-clonic (2)Usually 1 fit (2)Status epilepticus uncommon (consider other cause if present) (2)Alcoholic hallucinosis (AH) – visual, tactile or auditory hallucinations without disorientation Delirium tremens (DT) – visual, tactile or auditory hallucinations with disorientationMost severe form (2)Occurs in <5% of cases (7)Increases mortality if untreated (2) |
| Time to onset from last drink | 6-24 hours (1) | Seizures: 12-48 hours (2)AH: 24-48 hours (2)DT: 72-96 hours (2) |
Examination
- Vitals – hyperthermia, tachycardia, hypertension
- Neurological
- Confusion/ataxia/ophthalmoplegia ???? Wernicke’s encephalopathy → urgent (refer to Wernicke’s encephalopathy management below) (8)
- Pupillary reflexes – specific substance use syndromes
- Signs of chronic liver disease – presence may impact choice of pharmacological agent
Diagnosis #
Clinical diagnosis based on the following DSM-V diagnostic criteria: (9)
A. Cessation of (or reduction in) alcohol use that has been heavy and prolonged.
B. 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 A:
1. Autonomic hyperactivity
2. Increased hand tremor
3. Insomnia
4. Nausea or vomiting
5. Transient visual, tactile, or auditory hallucinations or illusions
6. Psychomotor agitation
7. Anxiety
8. Generalized tonic-clonic seizures
C. The signs or symptoms in criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. 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.
Investigations #
Initial investigations
| Investigation | Significance |
| FBE | Macrocytosis, thrombocytopenia |
| UEC | Lower BZ dose if severe renal impairment (10) Hypokalaemia common in alcohol withdrawal (2) |
| CMP | Hypomagnesaemia common in chronic alcohol use. May predispose to arrhythmias and seizures (2) Hypophosphataemia may be present due to malnutrition. If severe, may exacerbate or cause cardiac disease (2) |
| Finger-prick glucose | Hypoglycaemia is an important differential for seizures and altered conscious state |
| LFT | Alcoholic hepatitis/severe liver disease contraindications for diazepam treatment (2,10) |
| PT/INR | |
| Lipase |
Further investigations
| Investigation | Significance |
| ECG | Recommended for >50 years, or history of cardiac disease (5) |
| Blood alcohol level | Relevant if presenting to ED undifferentiated. Symptoms may occur even if levels are not 0 (3) |
| Urine drug screen | Substance use for other differentials |
| b-HCG (for premenopausal women) | Pregnancy symptoms overlap with some withdrawal symptoms If pregnancy and withdrawal co-exist, seek expert advice for safe treatment choice if pharmacological management is required |
| B12, folate | Patients with alcohol use disorder are at higher risk of malnutrition. Deficiency may precipitate some overlapping neurological symptoms with alcohol withdrawal. Optimise nutritional and metabolic derangements in alcohol withdrawal (6) |
| CXR | May be indicated in chronic respiratory disease or if pneumonia suspected as may exacerbate withdrawal symptoms (5) |
| CT-brain | Indicated if first seizure presentation, seizure atypical to previous, or suspicion for head injury (5) |
| Abdominal USS | May be indicated if patient reports abdominal pain (5). Evidence of underlying pancreatitis or complications secondary to it may exacerbate withdrawal symptoms (5) |
| CT-abdomen |
Classification #
Classification by severity scales (6)
The Clinical Institute Withdrawal Assessment of Alcohol, revised (CIWA-Ar)
- CIWA-Ar is the most extensively studied and used scale (2). Link here: https://www.mdcalc.com/ciwa-ar-alcohol-withdrawal
- Can be used to (4):
- Assess the severity of withdrawal symptoms to support treatment decision
- Monitor the progression of severity over time
- Do not use (4):
- To diagnose alcohol withdrawal
- If sedated or non-verbal patient
The Prediction Alcohol Withdrawal Severity Scale (PAWSS)
- PAWSS score ≥4 is the best predictor of clinically significant withdrawal (99.5% PPV, 93.1% NPV (11)) (12). Link here: https://www.mdcalc.com/prediction-alcohol-withdrawal-severity-scale
- Can be used (11):
- To assess risk of developing complicated alcohol withdrawal syndrome (i.e., hallucinosis, seizures, or delirium tremens), thereby, guiding decision to treat
- Before CIWA-Ar to predict risk of withdrawal severity
- Do not use if (11):
- Active seizures or withdrawal symptoms already present
- Sedated or non-verbal patient
Management #
Before proceeding, ensure:
- Patient does not have other severe medical and/or psychiatric condition that may mimic alcohol withdrawal syndrome
- A diagnosis of alcohol withdrawal has been confirmed
- Other concurrent medications have been reviewed, particularly opioids
For all individuals:
- Use appropriate scales provided above (or others by your hospital) to assess and/or monitor severity
- Monitor vitals, progression of symptoms, conscious state, electrolytes, and fluid status (6)
- Optimise environment – low stimuli, consistent nursing staff, orientation cues, etc, if possible (1)
- Provide supportive care – eg – fluids, nutrition (6)
- If pharmacological management is indicated, PO route for BZ is the preferred route if tolerated (1)
- Escalate management and seek senior clinician and/or expert advice as needed
- Re-consider diagnosis if symptoms persist (1)
- Offer social work and addiction medicine services for long-term treatment of alcohol use disorder. If accepted, refer once stable
Severe withdrawal #
- Make nil by mouth if risk of aspiration (2)
- May require ICU admission if symptoms do not resolve, significant comorbidities present, or complications develop (2)
- Reassess every 10-15 minutes. Once controlled, reassess every 1 hour (2)
No alcoholic hepatitis or severe liver disease:
| Diazepam 5-10 mg IV every 5-10 minutes, until appropriate level of sedation is attained (2) And Thiamine* 300 mg IM or IV daily for 3-5 days, then thiamine 300 mg PO daily for several weeks (1) |
If alcoholic hepatitis or severe liver disease present:
| Lorazepam 2-4 mg IV every 15-20 minutes, until appropriate level of sedation is attained (2) And Thiamine* 300 mg IM or IV daily for 3-5 days, then thiamine 300 mg PO daily for several weeks (1) |
- Other contraindications to BZs: respiratory depression, myasthenia gravis (10)
| *If treating hypoglycaemia, give thiamine before administering glucose (including glucose 5% IV) or else may precipitate Wernicke’s encephalopathy (1) |
If delirium tremens unresolved and anti-psychotic is required (1):
| Haloperidol 0.5-2 mg PO 2-hourly. Titrate to clinical response up to 10 mg in 24 hours Or If PO route unsuitable, haloperidol 5 mg IM single dose OR droperidol 5 mg IM single dose |
Mild-moderate withdrawal and high-risk individuals #
- Mild symptoms may not require pharmacological management, especially in low-risk patients (1). Provide reassurance (1)
- High-risk individuals (eg – PAWSS ≥4) require pharmacological management (11)
- If pharmacological treatment is given, reassess every 4-6 hours (2)
No alcoholic hepatitis or severe liver disease (1):
| Diazepam* 20 mg PO 2-hourly until symptoms resolve. A cumulative dose of 60 mg daily is usually adequate If symptoms return, may repeat dosing regimen for up to 7 days. However, advisable to seek senior medical advice And Thiamine** 300 mg IM or IV daily for 3-5 days, then thiamine 300 mg PO daily |
If alcoholic hepatitis or severe liver disease present:
| Oxazepam 10-30 mg PO every 6 hours until symptoms resolve (2) And Thiamine** 300 mg IM or IV daily for 3-5 days, then thiamine 300 mg PO daily (1) |
- Other contraindications to BZs: respiratory depression, myasthenia gravis (10)
| *Do not exceed 100 mg diazepam per day without seeking senior clinician or expert advice (1) **If treating hypoglycaemia, give thiamine before administering glucose (including glucose 5% IV) or else may precipitate Wernicke’s encephalopathy (1) |
Wernicke’s encephalopathy
| Thiamine 200-500 mg IV tds for 5-7 days; then 100 mg IV or IM daily, or 100 mg PO tds for 1-2 weeks; then 100 mg PO daily (8) |
