Alcohol Withdrawal Syndrome

Alcohol withdrawal syndrome follows abrupt cessation or substantial reduction of heavy, prolonged alcohol use. Diagnostic features include autonomic hyperactivity, tremor, insomnia, nausea or vomiting, perceptual disturbances, agitation, anxiety, or generalized tonic-clonic seizures; at least 2 symptoms should develop within hours to several days, cause clinically meaningful distress or impairment, and not be better explained by another condition.ScienceDirect+1ScienceDirectManaging Alcohol Withdrawal SyndromeccjmAlcohol withdrawal syndrome in medical patients

Symptoms may begin within 6 to 24 hours after the last drink, often peak over the next 2 to 3 days, and improve over several days. Withdrawal seizures usually occur within 6 to 48 hours, whereas delirium tremens generally begins after 48 to 72 hours.ScienceDirectScienceDirectAlcohol withdrawal syndrome in hospitalized patients: a practical review Withdrawal may occur despite a measurable blood alcohol concentration, particularly when the serum concentration is falling in a patient with physiologic dependence.ccjmccjmAlcohol withdrawal syndrome in medical patients

Do not attribute fever, hypoxemia, focal neurologic findings, unexpected obtundation, severe metabolic abnormalities, or refractory agitation solely to withdrawal. Reassess for infection, trauma or intracranial injury, hypoglycemia, toxicologic syndromes, hepatic encephalopathy, pulmonary embolism, thyroid disease, medication toxicity, and non-alcohol delirium.ScienceDirectScienceDirectAlcohol withdrawal syndrome in hospitalized patients: a practical review

PAWSS is useful early in hospitalized patients before withdrawal fully declares itself. A score of 4 or greater indicates high risk for complicated withdrawal and may support pharmacologic prophylaxis and monitored treatment.ScienceDirect+1ScienceDirectAlcohol withdrawal syndrome in hospitalized patients: a practical reviewScienceDirectAlcohol Withdrawal Syndrome - an overview CIWA-Ar measures current symptom burden on a 0-to-67 scale; commonly used ranges are less than 8 for minimal to mild symptoms, 8 to 15 for moderate symptoms, and greater than 15 for severe symptoms, but protocols vary and thresholds should not be used as stand-alone disposition rules.ScienceDirectScienceDirectAlcohol withdrawal syndrome in hospitalized patients: a practical review

Outpatient management is limited to carefully selected patients with mild to moderate symptoms, stable vital signs, reliable follow-up and social support, stable housing and transportation, and no history of complicated withdrawal or major unstable medical or psychiatric comorbidity.ScienceDirectScienceDirectAlcohol withdrawal syndrome in hospitalized patients: a practical review Moderate symptoms may be managed outside the hospital only when these conditions are met and reassessment is assured.ScienceDirectScienceDirectAlcohol withdrawal syndrome in hospitalized patients: a practical review

Obtain bedside glucose and evaluate volume status, electrolytes, liver injury, infection, and concurrent intoxication or withdrawal according to presentation. Repeated vital signs, mental-status assessments, and medication-response assessments are essential because oversedation, progression to complicated withdrawal, or an alternate diagnosis may become apparent during the first 24 to 48 hours.ScienceDirectScienceDirectAlcohol withdrawal syndrome in hospitalized patients: a practical review

Heavy alcohol use increases the risk of thiamine deficiency and Wernicke encephalopathy. Parenteral thiamine is preferred for hospitalized patients with malnutrition, vomiting, confusion, poor absorption, or severe or complicated withdrawal. In high-risk hospitalized patients, 100 mg IV or IM daily for 3 to 5 days is commonly used; suspected or manifest Wernicke encephalopathy warrants high-dose IV thiamine, commonly 200 to 500 mg IV 3 times daily for 3 to 5 days, followed by ongoing supplementation based on clinical response and local practice.ScienceDirectScienceDirectAlcohol withdrawal syndrome in hospitalized patients: a practical review

Correct hypoglycemia and clinically important potassium, magnesium, and phosphate abnormalities. Magnesium replacement is appropriate for hypomagnesemia, arrhythmia, electrolyte disturbance, or prior withdrawal seizures, but magnesium is not primary therapy for alcohol withdrawal itself.ScienceDirectScienceDirectAlcohol withdrawal syndrome in hospitalized patients: a practical review

Benzodiazepines are the standard first-line treatment for moderate to severe alcohol withdrawal because they relieve symptoms and reduce the risk of seizures and delirium.ScienceDirect+1ScienceDirectAlcohol withdrawal syndrome in hospitalized patients: a practical reviewWHOMental Health, Brain Health and Substance Use Symptom-triggered treatment is preferred for most noncritically ill inpatients when trained staff can reliably perform serial CIWA-Ar assessment; compared with fixed schedules, it can reduce benzodiazepine exposure and may reduce length of stay.ccjmccjmAlcohol withdrawal syndrome in medical patients

Common initial symptom-triggered doses cited for medical inpatients are chlordiazepoxide 25 to 50 mg, lorazepam 1 to 2 mg, or oxazepam 15 mg, with repeat assessment and titration according to the institutional protocol and patient response.ccjmccjmAlcohol withdrawal syndrome in medical patients Benzodiazepine selection should reflect pharmacokinetics, hepatic function, age, co-exposures, and the monitoring environment. Lorazepam or oxazepam may be preferred in significant hepatic dysfunction or older adults because they undergo glucuronidation and lack active metabolites.ScienceDirect+1ScienceDirectAlcohol withdrawal syndrome in hospitalized patients: a practical reviewccjmAlcohol withdrawal syndrome in medical patients

Fixed-dose or front-loading approaches are appropriate when symptom scoring is unreliable or when there is a history of severe withdrawal. In severe, refractory, or delirious withdrawal, escalation should occur in a monitored setting that can manage respiratory compromise and airway intervention.ScienceDirect+1ScienceDirectAlcohol withdrawal syndrome in hospitalized patients: a practical reviewccjmAlcohol withdrawal syndrome in medical patients

Alcohol withdrawal seizures and delirium tremens require urgent reassessment for competing etiologies, correction of metabolic abnormalities, and treatment in a setting capable of close respiratory and hemodynamic monitoring.ScienceDirectScienceDirectAlcohol withdrawal syndrome in hospitalized patients: a practical review Benzodiazepines remain the pharmacologic foundation; antipsychotics and autonomic agents are adjuncts rather than substitutes for adequate GABAergic therapy.ccjm+1ccjmAlcohol withdrawal syndrome in medical patientsWHOMental Health, Brain Health and Substance Use

For delirium tremens, serial CIWA-Ar is generally inappropriate because patient reporting is unreliable. Guide treatment by objective agitation, autonomic instability, attention, consciousness, airway safety, and response to sedatives, while repeatedly evaluating infection, trauma, intracranial pathology, hepatic encephalopathy, hypoxia, and toxidromes.ScienceDirectScienceDirectAlcohol withdrawal syndrome in hospitalized patients: a practical review

Acute withdrawal treatment should be followed by assessment and treatment planning for alcohol use disorder, including psychosocial support and recovery services.dailymed nlm nih+2dailymed nlm nihThese highlights do not include all the information needed to use ACAMPROSATE CALCIUM DELAYED-RELEASE TABLETS safely and effectively. See full prescribing information for ACAMPROSATE CALCIUM DELAYED-RELEASE TABLETS.ACAMPROSATE CALCIUM delayed-release tablets, for oral useInitial U.S. Approval: 2004acpjournalsThe Management of Substance Use DisordersScienceDirectAlcohol withdrawal syndrome in hospitalized patients: a practical review For patients in early recovery or after relapse, peer, network, or 12-step facilitation may be offered as part of ongoing care.acpjournalsacpjournalsThe Management of Substance Use Disorders

FDA-labeled pharmacotherapy may be considered once the acute withdrawal phase is addressed and patient-specific contraindications are reviewed. Acamprosate is indicated to maintain abstinence in alcohol-dependent patients who are abstinent when treatment begins and should be combined with psychosocial support.dailymed nlm nihdailymed nlm nihThese highlights do not include all the information needed to use ACAMPROSATE CALCIUM DELAYED-RELEASE TABLETS safely and effectively. See full prescribing information for ACAMPROSATE CALCIUM DELAYED-RELEASE TABLETS.ACAMPROSATE CALCIUM delayed-release tablets, for oral useInitial U.S. Approval: 2004 Extended-release injectable naltrexone is indicated for alcohol dependence in patients able to abstain before initiation; patients should not be actively drinking at first administration and must be assessed for opioid exposure or dependence.dailymed nlm nihdailymed nlm nihThese highlights do not include all the information needed to use VIVITROL® safely and effectively. See full prescribing information for VIVITROL. VIVITROL (naltrexone for extended-release injectable suspension), for intramuscular useInitial U.S. Approval: 1984