Recommendations

Key Recommendations

There can be multiple reasons for alcohol-dependent patients to decrease or stop drinking, including financial or social issues, a self-motivated effort to reduce or abstain from drinking, or an acute medical condition (e.g., pancreatitis, infection, trauma). Therefore, a thorough evaluation of the reasons and/or underlying medical conditions that may have led to changes in the individual's drinking behavior is essential.

Patients can present hours to days after their last drink, with a spectrum of signs and symptoms of alcohol withdrawal syndrome (AWS), including autonomic hyperactivity, tremulousness, restlessness, seizures, and potentially life-threatening alcohol withdrawal delirium (also known as delirium tremens). Patients may not be able to provide accurate information regarding the reason for presenting. If possible, information should be obtained from other available sources (e.g., family, friends, bystanders, or prehospital providers) to exclude conditions that can mimic AWS.[5][10]

Clinical assessment

All patients require a thorough history and physical examination to evaluate the current severity of withdrawal, and to assess the risk of complicated withdrawal or life-threatening symptoms.[5] Patients presenting with seizures should also have a neurologic examination.[5] Patients should be screened for alcohol use disorder (AUD) using a formal assessment tool such as AUDIT-C (Alcohol Use Disorders Identification Test - Consumption), CAGE, or FAST (Fast Alcohol Screening Test).[3][5][43]​​ [ Alcohol Consumption Screening AUDIT Questionnaire Opens in new window ] Alcohol use disorders identification test consumption (AUDIT C) Opens in new window CAGE questionnaire Opens in new window Fast Alcohol Screening Test (FAST) Opens in new window

The patient's medical and medication history should be reviewed to assess for other illnesses that could mimic AWS (e.g., diabetic ketoacidosis or hypoglycemia), or medications that could potentially mask the signs/symptoms of AWS (e.g., beta-blockers).[5] If the patient presents with hallucinations, aim to identify whether these are related to alcohol withdrawal delirium, alcohol-induced psychotic disorder (alcoholic hallucinosis), or another cause.[5] It is important to remember that alcohol withdrawal often accompanies another pathology, including withdrawal from other substances; patients should also be screened for other substance use and potential withdrawal syndromes.[5] It may be useful to evaluate the patient for associated psychiatric conditions, including depression, using a questionnaire such as the Patient Health Questionnaire (PHQ-9) or Generalized Anxiety Disorder (GAD 7).[5] Suicide risk should be assessed as part of the initial patient evaluation.[5]

AWS can be classified by timing (early vs. late) and severity (uncomplicated vs. complicated; and mild, moderate, and severe). In addition to clinical judgment, a validated scoring system should be used to assess severity and guide management; examples include the Clinical Institute Withdrawal Assessment for Alcohol scale, revised version (CIWA-Ar), Prediction of Alcohol Withdrawal Severity Scale (PAWSS), and the ASAM Criteria Risk Assessment Matrix.[5] CIWA-Ar Opens in new window PAWSS Opens in new window

No one scale has been shown to be more effective than another, but the CIWA-Ar assessment is the most commonly used.[5] CIWA-Ar can be performed in approximately 5 minutes, but it requires subjective reporting by the patient.[11][24][52] The CIWA-Ar may, therefore, be difficult to administer to acutely agitated patients, sedated patients, and patients with language barriers. Simplified assessment scales, such as the Brief Alcohol Withdrawal Scale (BAWS), have been developed to address these limitations but have not been extensively evaluated.[53] Clinical prediction tools based on combinations of symptoms and signs may be helpful in predicting the development of moderate to severe AWS in medically ill/hospitalized patients. One systematic review evaluated the predictive utility of signs and symptoms in identifying at-risk patients for severe AWS and found the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) to be most useful.[50]

Presentation by severity

Mild to moderate AWS (CIWA-Ar score <10 [mild], 10-19 [moderate]):[5][6]

  • Nausea and vomiting

  • Tachycardia

  • Anorexia

  • Anxiety and restlessness

  • Emotional lability

  • Insomnia

  • Irritability

  • Diaphoresis

  • Headache

  • Fine tremor

  • Agitation.

Severe/complicated AWS (CIWA-Ar >19):[5][47][54]​​

  • A worsening CIWA-Ar or other score used to assess severity.

  • Failure to improve after two doses of a benzodiazepine.

  • Deranged temperature, or deranged blood pressure, or deranged blood glucose, alongside any feature of alcohol withdrawal.

    • Hypertension and fever are more commonly seen than hypotension or hypothermia.

  • Visual, auditory, and tactile hallucinations

    • Characteristically frightening, involving insects on the skin or animals circling the bed.

    • Experienced by about 25% of patients with AWS.

    • Usually start within 12-24 hours of reduction or cessation of alcohol intake.[5][12]

    • Do not always progress to alcohol withdrawal delirium and will usually resolve within 24-48 hours if no other signs and symptoms of alcohol withdrawal delirium develop.[5]

  • Alcohol withdrawal delirium[1][2][6]

    • This is a medical emergency and is present in around 5% of patients with AWS.[11] Alcohol withdrawal delirium tends to start 48-72 hours after the patient’s last alcoholic drink, and symptoms peak at 5 days.[1][5][6] Features of alcohol withdrawal delirium include:

      • Profound confusion[11][12]

      • Delusions

      • Coarse tremor[12]

      • Signs of clinical instability including tachycardia, hyper/hypotension, fever, ketoacidosis, and circulatory collapse.[12]

  • Alcohol withdrawal seizures:

    • Typically occur in the first 12-48 hours after the last alcoholic drink, with a peak at around 24 hours.[1][2][5][12]

    • Signs of an imminent seizure can include tremor, hypertension, tachycardia, fever, and hyperreflexia, though alcohol withdrawal seizures may occur in the absence of other clinical signs or symptoms of acute withdrawal.[5]

    • Patients with a history of alcohol withdrawal seizures or those who experienced a seizure due to acute alcohol withdrawal are at a higher risk of experiencing recurrent seizures.[5]

Risk factors for severe or complicated alcohol withdrawal include:[5]

  • Comorbid surgical or medical conditions, in particular, traumatic brain injury (TBI).

  • Age over 65 years, though this may be confounded by the association of age with increased number and complexity of comorbidities.

  • Duration of alcohol intake - regular and excessive alcohol intake for a long period of time may increase the risk of severe withdrawal, though this may also be associated with age and presence of comorbidities.

  • Seizures during the current or previous episode of withdrawal. Following a seizure, the risk of repeat seizure and progression to alcohol withdrawal delirium is increased.

  • Presentation with significant autonomic hyperactivity and CIWA-Ar score at presentation greater than 10.

  • Concomitant medications or drug dependence, in particular use of benzodiazepines or barbiturates, such that there is physiologic dependence.

  • Current physiologic dependence on another addictive substance or withdrawal from another substance.

  • Signs and symptoms of withdrawal with a detectable blood alcohol level are associated with severe and complicated AWS, because AWS typically only develops when blood ethanol levels decrease in a period of alcohol abstinence or decreased consumption.

  • Clinical evidence of an active co-existing psychiatric condition.

Laboratory tests and imaging

There is no specific role for laboratory tests or imaging studies in the diagnosis of AWS; it is a clinical diagnosis. Basic laboratory tests such as complete blood count, electrolytes, liver function tests (e.g., aspartate aminotransferase and alanine aminotransferase), and glucose levels should be obtained to exclude other causes of the patient’s presentation (such as uremic encephalopathy), infections, hypoglycemia, electrolyte abnormalities associated with alcohol use or dehydration (e.g., in a patient with delirium), and to guide medical management; for example, in the presence of impaired hepatic function, which would necessitate dose adjustment of medications.[5] Imaging studies such as chest x-ray and computed tomography (CT) of the brain may be obtained to exclude cardiopulmonary and intracranial pathologies that may mimic alcohol withdrawal. If a patient presents with new onset seizures, or there is a new pattern of seizures in a patient with a known history of withdrawal seizures, electroencephalogram (EEG) and/or neuroimaging may be indicated.[5] Initial assessment may also include screening for medical conditions with a high rate of co-occurrence with alcohol withdrawal such hepatitis, tuberculosis, and HIV.[5]

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