Alcohol Withdrawal

Question 1

50 year old man with History of alcohol dependence stops drinking suddenly. 10hrs later, presented with tremors, anxiety and mild nausea. Vitals: HR96, BP130/80, alert and oriented. What is initial management?

A) Haloperidol
B) IV Lorazepam
C) Chlordiazepoxide (PO) with monitoring
D) Phenytoin

Answer 1

C) Chlordiazepoxide (PO) with monitoring (MILD withdrawal)

A and B - (Anti PSY not allowed due to increased risk of seizures)
D - (Only if seizure not controlled)

Question 2

40yo man presents 2 days after stopping alcohol. He has tremors, sweating, tachycardia (HR120) and high BP160/100. Anxious but oriented. What is next best step?
A) Oral Disulfiram
B) Betablockers only
C) Diazepam or Lorazepam under medical supervision
D) No medication (Monitoring only)

Answer 2

C) Diazepam or Lorazepam under medical supervision (MOD withdrawal)

A - (Maintenance of AUD not treatment of withdrawal)
B - (Adjunct therapy not monotherapy)
D - May be life threatening

Question 3

38yo man prevents with confusion, hallucinations, tremors and BP 180/110. History of heavy alcohol use and last drank 3 days ago. What is immediate priority?
A) Start Disulfiram
B) Oral Chlordiazepoxide
C) IV Diazepam or Lorazepam
D) Acamprosate

Answer 3

C) IV Diazepam or Lorazepam (SEVERE withdrawal)

A - (not maintenance)
b - (Maintenance)

Question 4

45yo man recently completed alcohol detoxification is motivated to remain abstinent. He is concerned about relapse and seeks medical support. He has no liver or kidney issues. What is an appropriate first-line agent for relapse prevention?

A) Lorazepam
B) Naltrexone
C) Dexmedetomidine
D) Phenytoin

Answer 4

B) Naltrexone (Maintenance phase)

A - (Withdrawal management)
C - (Withdrawal management)
D - (Seizure)

Question 5

Patient in ICU is receiving high dose lorazepam for alcohol withdrawal. He remains agitated and tachycardic. What adjunct medication may be added to control hyperadrenergic symptoms?

A) Naltrexone
B) Acamprosate
C) Dexmedetomidine
D) Haloperidol

Answer 5

C) Dexmedetomidine (REFRACTORY withdrawal)

Question 6

52yo man on Disulfiram accidentally drinks wine at a party. He develops flushing, nausea, palpitations and dizziness. What is the underlying mechanisms
A) Serotonin symptom
B) Alcohol interaction causing acetaldehyde buildup
C) Opioid receptor blockage
D) Dopamine surge in nucleus accumbent

Answer 6

B) Alcohol interaction causing acetaldehyde buildup

Question 7

A 45-year-old man with alcohol dependence presents with tremors, nausea, and anxiety 12 hours after his last drink. He has stable vitals. What is the first-line treatment?

A. Haloperidol
B. Lorazepam
C. Disulfiram
D. Naltrexone

Answer 7

B
Lorazepam
Benzodiazepines are first-line in alcohol withdrawal. Lorazepam is preferred in liver impairment

Question 8

Why should antipsychotics be avoided in alcohol withdrawal syndrome?

A. They cause dehydration
B. They worsen euphoria
C. They increase seizure risk
D. They have no CNS effects

Answer 8

C
They increase seizure risk
Antipsychotics lower the seizure threshold and may worsen withdrawal symptoms.

Question 9

What is the pathophysiology of alcohol withdrawal symptoms?

A. Decreased dopamine activity in the mesolimbic system
B. Upregulation of GABA receptors
C. Rebound hyperactivity of glutamate (NMDA) receptors
D. Inhibition of serotonin pathways

Answer 9

C. Rebound hyperactivity of glutamate (NMDA) receptors
Withdrawal causes excitatory pathways to rebound due to previous suppression by alcohol.

Question 10

Which of the following drugs is used as adjunct therapy for severe alcohol withdrawal that is unresponsive to benzodiazepines?

A. Topiramate
B. Dexmedetomidine
C. Disulfiram
D. Ondansetron

Answer 10

Dexmedetomidine
Used for sedation in refractory AWS, with minimal respiratory depression.

Question 11

Which of the following alcohol deterrent agents works by inhibiting aldehyde dehydrogenase?

A. Naltrexone
B. Disulfiram
C. Acamprosate
D. Topiramate

Answer 11

B. Disulfiram
Causes acetaldehyde accumulation → unpleasant symptoms when alcohol is consumed.

Question 12

Which medication is most appropriate for an alcohol-dependent patient with liver cirrhosis?

A. Disulfiram
B. Naltrexone
C. Acamprosate
D. Diazepam

Answer 12

C. Acamprosate
Renally excreted, not hepatotoxic — safe in liver disease.

Question 13

A patient receiving naltrexone IM reports improved adherence. What is a key advantage of the IM form?

A. Blocks GABA receptors directly
B. Causes aversion to alcohol
C. No hepatic metabolism
D. Must be taken daily

Answer 13

C. No hepatic metabolism
The IM form bypasses first-pass metabolism, reducing hepatotoxicity risk.

Question 14

Which medication for alcohol dependence reduces cravings by antagonizing opioid receptors?

A. Disulfiram
B. Naltrexone
C. Baclofen
D. Ondansetron

Answer 14

B. Naltrexone
Blocks reward-related dopamine release mediated by endogenous opioids.

Question 15

Outline the management of moderate alcohol withdrawal and explain the role of benzodiazepines and thiamine in treatment.
(5 marks)

Answer 15

Moderate alcohol withdrawal requires inpatient management and symptom-guided therapy using CIWA-Ar.

Benzodiazepines (e.g., lorazepam, diazepam) are first-line to prevent seizures and reduce CNS hyperexcitability.

Thiamine (Vitamin B1) is given IV or PO to prevent Wernicke’s encephalopathy, ideally before glucose to avoid precipitating Korsakoff syndrome.

Other supportive care includes fluids, electrolyte correction, and symptom-specific medications.