alcohol withdrawal syndrome

Etiology

• chronic ethanol ingestion
• isopropanol & methanol less frequently ingested

Epidemiology

• 5-10% of population have chronic alcoholism
  • only some will experience withdrawal upon abrupt discontinuation of alcohol
• increasing age is associated with increasing severity & duration of alcohol withdrawal symptoms

Pathology

• adaptive responses to long-term use produce tolerance
• adpative responses persist after discontinuation of alcohol
• adaptive responses include:
  • downregulation of GABA-A receptors
  • increase synthesis of excitatory neurotransmitters
    • norepinephrine, dopamine, serotonin
  • upregulation of NMDA receptors
  • upregulation of opioid receptors
    • nucleus accumbens & ventral tegmental area
    • results in alcohol craving

History

• time of last drink
• how much for how long
• why did the patient stop drinking
• previous history of withdrawal (including delirium tremens)
• AUDIT* useful screen for inpatients at risk of alcohol withdrawal

Clinical manifestations

• occurs within < 24 hours to 5 days after cessation or significant decrease in alcohol consumption; 6-36 hours
• severity is generally maximum after 50 hours
• signs & symptoms
  • autonomic hyperactivity
  • anorexia
  • insomnia
  • irritability, generalized tonic-clonic seizure*
    • within 2 days of last drink
    • 6-24 hours after last drik
  • tremor, anxiety, diaphoresis, palpitations 6-36 hours after last drink
  • tachycardia
  • hypertension
  • fever
  • hyperreflexia
  • disorientation
  • hallucinations
    • auditory, visual, tactile
    • 12-48 hours after last drink
    • hallucinations do not cloud sensorium
  • sensation of bugs crawling on skin
  • delirium tremens 48-96 (24-48) hours after last drink
• signs & symptoms from complications of alcoholism

* multiple seizures suggest another disorder

Laboratory

• blood glucose (finger stick)
• complete blood count (MCV)*
• blood alcohol
• chem 7
• serum amylase & serum lipase
• liver function tests,* ALT, AST, GGT
• urinalysis
  • urine ketones
  • urine toxicology

Diagnostic procedures

• electrocardiogram:
  • increased myocardial demand may precipitate myocardial infarction
  • prolonged QTc reverts to normal after resolution of withdrawal symptoms

Radiology

• chest X-ray
  • aspiration pneumonia is common
  • cardiomyopathy & CHF may be observed
• head CT
  • head trauma may result in intracranial bleed

Differential diagnosis

• pancreatitis
• alcoholic ketoacidosis
• anxiety
• hypoglycemia
• hypophosphatemia
• anxiety
• panic disorder
• sympathomimetic toxicity

Management

• hospitalize for
  • severe alcohol withdrawal (anticipated)
  • lack of social support
• thiamine 100 mg (IM) PRIOR to food or glucose administration
• benzodiazepines
  • indications:
    • previous alcohol-related seizures
      • long-acting benzodiazepine on a fixed schedule is indicated even in the absence of symptoms
    • history of delirium tremens
    • significant withdrawal symptoms
    • more severe of longstanding alcohol dependence
    • history of failed or multiple detoxification attempts
    • acute medical illness or surgical illness
    • currently pregnant
  • symptom-triggered benzodiazepine for alcohol withdrawal in hospitalized patients results in shorter course of therapy & less benzodiazepine use
  • agents of choice
    • chlordiazepoxide in patients without cirrhosis or hepatitis
      • long 1/2 life
    • oxazepam 15-30 mg PO every 6-8 hours
    • lorazepam 2-4 mg IV every 2 hours PRN
    • lorazepam or oxazepam if cirrhosis or hepatitis
  • alternative agents
    • midazolam (Versed)
    • diazepam (non-inferior to lorazepam)
  • regimens
    • taper over 5-7 days
    • symptom-triggered dosing (vs taper)
      • shorter hospital stays (2 vs 3 days)
      • lower total benzodiazepine doses (equivalent to 80 mg vs 170 mg of diazepam)
  • not all heavy drinkers who stop abruptly will have symptoms of withdrawal & benzodiazepine is not always needed
• propofol (Diprivan) hospitalized ICU patients with severe withdrawal
• clonidine 0.1-0.2 mg TID
  • can help with attenuation of sympathetic discharge
  • allows for sedation with lower doses of sedatives
  • monitor blood pressure
• propranolol
  • may help control hypertension & tachycardia
  • may be useful in patients with cirrhosis & esophageal varices
  • not be use as monotherapy in treatment of alcohol withdrawal
• carbamazepine, valproate, gabapentin may be used as adjunctive therapy
• antipsychotics lower the seizure threshold (avoid)
• dihydropyridines of may be benefit in rodents
• oral vitamins
  • thiamine 100 mg PO QD
  • folate 1 mg PO QD

More general terms

• substance withdrawal
• syndrome

More specific terms

• alcohol withdrawal seizure
• delirium tremens (DT's)

Additional terms

• alcoholism (includes binge drinking)