Alcohol Withdrawal

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Alcohol withdrawal syndrome (AWS) is a spectrum of symptoms that results from abrupt cessation or reduction in alcohol intake, which has previously been heavy or prolonged. Symptoms generally start 6 to 24 hours after the last drink.


  • 15.1 million Americans meet diagnostic criteria for alcohol use disorder (AUD). Approximately 50% of those with AUD have experienced AWS in their lifetime.
  • 8% of those admitted to the hospital are at risk for AWS.
  • Higher prevalence in men, whites, Native Americans, younger and unmarried adults, and those with lower socioeconomic status

Etiology and Pathophysiology

  • Consumption of alcohol potentiates the effect of the inhibitory neurotransmitter γ-aminobutyric acid (GABA). With chronic alcohol ingestion, this repeated stimulation downregulates the inhibitory effects of GABA.
  • Concurrently, alcohol ingestion inhibits the stimulatory effect of glutamate on the CNS, with chronic alcohol use upregulating excitatory NMDA glutamate receptors.
  • When alcohol is abruptly stopped, the combined effect of a downregulated inhibitory neurotransmitter system (GABA modulated) and upregulated excitatory neurotransmitter system (glutamate modulated) results in brain hyperexcitability when no longer suppressed by alcohol; clinically seen as AWS

Some evidence for a genetic basis of AUD

Risk Factors

  • High tolerance, prolonged use, high quantities
  • Previous alcohol withdrawal episodes, detoxifications, alcohol withdrawal seizures, and delirium tremens (DTs)
  • Serious medical problems
  • Concomitant benzodiazepine (BZD) use

Geriatric Considerations
Elderly with AUD are more susceptible to withdrawal, and chronic comorbid conditions place them at higher risk of complications from withdrawal; use of short-acting medications preferred for management

Pregnancy Considerations
Hospitalization or inpatient detoxification is usually required for treatment of acute alcohol withdrawal.

General Prevention

  • Routinely screen all adults for alcohol misuse (1)[B].
  • Screen with the CAGE or similar questionnaire.
    • Feeling the need to Cut down
    • Annoyed by criticism about alcohol use
    • Guilt about drinking/behaviors while intoxicated
    • Eye opener” to quell withdrawal symptoms
    • Useful to detect problematic alcohol use; positive screen is ≥2 “yes” responses.
  • Three-question AUDIT-C screening test is also useful to identify problem drinking.

Commonly Associated Conditions

  • General: poor nutrition, electrolyte abnormalities (hyponatremia, hypomagnesemia, hypophosphatemia), thiamine deficiency, dehydration
  • GI: hepatitis, cirrhosis, esophageal varices, GI bleed
  • Heme: splenomegaly, thrombocytopenia, macrocytic anemia
  • Cardiovascular: cardiomyopathy, hypertension, atrial fibrillation, other arrhythmias, stroke
  • CNS: trauma, seizure disorder, generalized atrophy, Wernicke-Korsakoff syndrome
  • Peripheral nervous system: neuropathy, myopathy
  • Pulmonary: aspiration pneumonitis or pneumonia; increased risk of anaerobic infections
  • Psychiatric: depression, posttraumatic stress disorder, bipolar disease, polysubstance use disorder

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