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Alcohol Withdrawal

Hasan Shabbir, MD
January 10th, 2008
• 8 million Alcoholics in US1,2
• 4 million hospitalizations for AWS/yr4
• 12-30% of inpatients have ongoing excess
alcohol intake3
• Not well understood
• Alcohol causes CNS depression
• Inhibits dopaminergic and adrenergic
• GABA like effects
• Cessation results in brain hyperexcitability
Definition-DSM IV
• 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 Criterion A: 1) autonomic
hyperactivity (e.g., sweating or pulse rate greater than 100)
2) increased hand tremor
3) insomnia
4) nausea or vomiting
5) transient visual, tactile, or auditory hallucinations or
6) psychomotor agitation
7) anxiety
8) grand mal seizures
C. The symptoms in Criterion B cause clinically significant
distress or impairment in social, occupational, or other
important areas of functioning.
D. The symptoms are not due to a general medical condition
and are not better accounted for by another mental disorder.
Alcoholic Hallucinosis
• 10-25% of patients with AWS hallucinate
• Usually in first 24-48hrs of cessation 7,10
• Does not predict DT’s
• Usually auditory or visual
• Formication (bugs crawling on skin)
“Minor” Withdrawal
• May occur within 6-12hrs of cessation
• Need to treat promptly
• May take up to 2 weeks to resolve
• Autonomic hyperactivity
– anxiety, tremulousness, insomnia
– hypertension, tachyarrythmias
– nausea, vomiting, or diarrhea
– Myalgias
Alcohol Withdrawal Seizures
• Usually Generalized Tonic Clonic Seizures
• Usually self-limited
• 90% occur within 8-48hrs of cessation
• Usually 12-24hrs post-cessation
• May occur without any warning
• Most recurrent seizures within 6hrs of first
Alcohol Withdrawal Seizures (cont.)
• Further work-up if
– Fever
– Trauma
– 1st seizure
– Focal seizure
– No clear history of alcohol use & cessation
– Status Epilepticus
Delirium Tremens
• Occurs in 5-8% of patients hospitalized with alcohol
• Occurs 2-14 days after cessation, can last 2 weeks!
• Fever, severe autonomic hyperactivity, agitation,
• Global disorientation is a key feature
• Mortality 5% with treatment (20% without Tx)
• Risk factors
– Age>30
– Hx of DTs or AW Seizures
– Concurrent Medical Illness
– Time since last drink
• Differential Dx?
• Special History Questions
– Quantity and Frequency of Consumption
– Detoxification History
– History of DTs and AW Seizures
– History “Crosscheck”
– Hallucinations
– Time of last drink
Assessment (cont.)
• Physical
– Hemodynamics, Neurologic Exam, Mental
– Stigmata of Liver Disease
– Nutritional Status

– Labs
General Treatment
• ICU? HR>130, • Vitamins
SBP>180, severe • Nutrition
agitation • Volume replacement
• Electrolyte correction
• 10-20% need to be • Benzodiazepines
• Other
– Severe withdrawal
– Poor social support
– Inability to tolerate
liquids or oral meds
• Prophylactic dose to reduce risk of AW
Seizures for all patients being admitted
with a medical or surgical problem
• Symptom Triggered OR
• Fixed Dose
Sample Regimens
Fixed Dose Regimen Symptom Triggered Regimen
• Standing dose, THEN: • Standing dose, THEN:

• Diazepam 20 mg PO QID for 4 • Diazepam 20 mg PO

doses then once PRN CIWA-Ar ≥8 every
• Diazepam 10 mg PO QID for 8 two hours

• Modified from: Saitz R, Mayo-

Smith MF, Roberts MS, et al.
Individualized treatments for
alcohol withdrawal: a
randomized double-blind
controlled trial. JAMA 1994;
• NAUSEA AND VOMITING — Ask "Do you feel sick to your stomach? Have you vomited?" Observation.

• TREMOR — Arms extended and fingers spread apart. Observation.

• PAROXYSMAL SWEATS — Observation.

• ANXIETY — Ask "Do you feel nervous?" Observation.

• AGITATION — Observation.

• TACTILE DISTURBANCES — Ask "Have you any itching, pins and needles sensations, burning
sensations, numbness or do you feel bugs crawling on or under your skin?" Observation.

• AUDITORY DISTURBANCES — Ask "Are you more aware of sounds around you? Are they harsh? Do they
frighten you? Are you hearing anything that is disturbing to you? Are you hearing things you know are not
there?" Observation.

• VISUAL DISTURBANCES — Ask "Does the light appear to be too bright? Is its colour different? Does it
hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are
not there?" Observation.

• HEADACHE, FULLNESS IN HEAD — Ask "Does your head feel different? Does it feel as if there is a band
around your head?" Do not rate for dizziness or lightheadedness. Otherwise, rate severity.

• ORIENTATION AND CLOUDING OF SENSORIUM — Ask "What day is this? Where are you? Who am I?"
Choice of Benzodiazepines
• Drug Half-Life Route Dose Equivalence

• Diazepam (Valium) IV 20–50 hr IV, PO 10 mg

• Chlordiazepoxide (Librium)6–25 hr IV, PO 50 mg

• Clorazepate (Tranxene)48–96 hrPO 15 mg

• Lorazepam (Ativan) 10–15 hr PO, IV, IM 2mg

• Oxazepam (Serax) 6–8 hr PO 30 mg

• Dose of IV Lorazepam post-seizure
– Recurrence 3% vs 22%
Delirium Tremens
• Usually need ICU setting
• Vascular access
• Telemetry monitoring
• Pharmacotherapy until patient alert and
• Benzodiazepines are mainstay
• May need additional medications for
cases refractory to benzodiazepines
Adjunctive Pharmacotherapy
• Haloperidol
• Baclofen
• Beta Adrenergic Antagonists
• Propofol
• Phenobarbital
• Mental Status & Hemodynamics
• Substance abuse follow-up
• Meds to decrease alcohol craving?
– Atenolol
– Topiramate
– Acamprosate
Take Home Points
• Common and Potentially Fatal
• Catch early by careful history
• One-time benzo for AW Seizure Prophylaxis
• Long-acting benzos are mainstay of treatment
• Fixed Dose and Symptom Triggered
• DTs includes global confusion
• Substance Abuse follow-up
• Don’t forget phenobarbital and propofol
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