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Alcohol withdrawal occurs when an individual suddenly stops drinking after heavy and/or prolonged alcohol use.1-3 As alcohol alters the balance of inhibitory and excitatory neurotransmitters, when alcohol is abruptly halted, this can cause excessive excitatory neuronal activity and cause alcohol withdrawal symptoms to develop.4,5
Aetiology
Symptoms of Alcohol Withdrawal Syndrome (AWS) may develop after the abrupt discontinuation or decrease of alcohol consumption. Symptoms can vary from autonomic hyperactivity and agitation to delirium tremens.6
AWS represents a clinical condition characterised by symptoms such as agitation, tremors, irritability, anxiety, hyperreflexia, confusion, hypertension, tachycardia, fever and diaphoresis. AWS usually develops in alcohol-dependent patients within 6–24 hours after the abrupt discontinuation or decrease of alcohol consumption. It is a potentially life-threatening condition whose severity ranges from mild/moderate forms characterised by tremors, nausea, anxiety, and depression, to severe forms characterised by hallucinations, seizures, delirium tremens and coma.
The mild-moderate form of AWS is often self-managed by patients or disappears within 2–7 days from the last drink, while more severe AWS requires medical treatment, often with benzodiazepines. The identification and subsequent treatment of AWS is of paramount clinical importance, given that AWS is one of the causes of preventable morbidity and mortality.
Epidemiology
Patients at a higher risk of developing more severe complications include those who have:5
- Extreme alcohol dependence
- Higher levels of alcohol intake
- Prolonged period of alcoholism
- Abnormal liver function
- Previous detoxification
- Previous experience of seizures or delirium tremens
- Intense craving for alcohol
- Concomitant acute illness
- Older age
- Use of other drugs in addition to alcohol
Pathophysiology
Alcohol withdrawal symptoms can vary from minor symptoms such as insomnia and tremulousness to more severe complications such as withdrawal seizures, delirium tremens and death.4,7
If alcohol intake has stopped suddenly, then two or more of the below (within several hours to a few days) can be a sign of alcohol withdrawal:4
- Autonomic hyperactivity (e.g., sweating or pulse rate greater than 100 beats per minute)
- Increased hand tremor
- Insomnia
- Nausea or vomiting
- Transient visual, tactile, or auditory hallucinations or illusions
- Psychomotor agitation
- Anxiety
- Grand mal seizures
Guidelines
There are many organisations that provide guidelines, advice and recommendations for alcohol misuse and the conditions associated with high alcohol intake. These include:
NICE Clinical Guidance
NICE Clinical Guidance 100 offers recommendations on managing acute alcohol withdrawal and treatment for a variety of alcohol-related conditions.
For more information, you can visit the guidelines here.
BNF
The BNF on alcohol dependence offers recommendations and treatment options for assisted alcohol withdrawal, alcohol dependence and Wernicke’s Encephalopathy.
For more information, you can access the BNF here.
The Royal College of Emergency Medicine (RCEM)
The RCEM provides an alcohol toolkit for emergency staff. The toolkit provides information on early identification and brief alcohol advice to patients along with the recommended pathway and treatment recommendations for alcohol-related conditions.
Differential diagnosis
Wernicke’s in non-alcoholic patients is less recognised and often misdiagnosed. Causes of Wernicke’s include:8
- Cancer
- Gastrointestinal surgery
- Hyperemesis gravidarum
- Starvation/fasting
- Gastrointestinal tract diseases
- AIDS
- Malnutrition
- Dialysis and renal disease
- Parenteral nutrition
- Persistent or recurrent vomiting
- Anorexia nervosa
- Stem cell/bone marrow transplantation
Staging
Chronic alcohol misusers enter a high-risk period during acute alcohol withdrawal, with several potential unpleasant and serious sequelae that usually peak within 10-30 hours and subside by 40-50 hours after the last alcoholic drink.9
Related auditory and visual hallucinations are characteristically frightening, and usually last 5 or 6 days.9
Prognosis
It may not be clear how thiamine deficient the patient is when coming into the hospital.
Treat early and every time before it becomes a medical emergency.10-12
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References
1. Alcohol Withdrawal, Alcohol rehab guide. Available from: https://www.alcoholrehabguide.org/alcohol/withdrawal/ Last accessed June 2023.
2. What is alcohol withdrawal? WebMD. Available from: https://www.webmd.com/mental-health/addiction/alcohol-withdrawal-symptoms-treatments#1 Last accessed June 2023.
3. Mayo-Smith M.F, et al. Arch Intern Med. 2004;164(13):1405-1412.
4. Bayard, M, et al. Am Fam Physician. 2004; 15;69(6):1443-1450.
5. Saitz, R. Alcohol Health Res World. 1998; 22(1): 5-12.
6. Mirijello A et al. Identification and management of alcohol withdrawal syndrome. Drugs 2015 March;75(4): 353–365.
7. Alcohol dependence, British National Formulary. Available from: https://bnf.nice.org.uk/treatment-summary/alcohol-dependence.html Last accessed June 2023.
8. Buchanan M et al. MGP Best practice guidance. Consensus guidance on the identification and management of Wernicke’s encephalopathy. Guidelines in Practice. November 2018.
9. McIntosh C, Chick J. J Neurol Neurosurg Psychiatry. 2004, 75 Suppl III; iii16-iii21.
10. Thomson AD. Alcohol Alcohol 2000;35 Suppl 1:2–7.
11. Thomson AD et al. Alcohol Alcohol 2002. 37; 513-521.
12. Sechi G, Serra A. Lancet Neurol 2007;6:442–455.
13. Sullivan JT, Sykora, K, Schneiderman, J, et al. Br J Addict. 1989 Nov; 84:1353-1357.
KKI/GB/PAB/0278 November 2023