Description

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.

Epidemiology

• 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

Genetics
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