Alcohol Withdrawal

Question 1

Define alcohol withdrawal.

Answer 1

Syndrome in patients who are alcohol-dependent and have stopped or reduced their alcohol intake within hours or days of presentation.

Symptoms usually begin 6-24hrs after patient’s last alcoholic drink and may progress to DT if left untreated.

Question 2

What is the epidemiology of AWS?

Answer 2

• 43% of the world consumes alcohol
• ~8% of all patients admitted to hospital are at risk of alcohol withdrawal
• 5% will progress to DT 48-72hrs after last drink if left untreated

Question 3

What are the risk factors for alcohol withdrawal syndrome?

Answer 3

History of AWS and delirium tremens

Abrupt alcohol withdrawal - severity of symptoms that occur when alcohol use is abruptly ceased is proportional to the previous duration and amount of alcohol consumed.

Question 4

Describe the pathophysiology of AWS.

Answer 4

Overactivity of the sympathetic nervous system; alcohol is a depressant.

Chronic alcohol use results in up-regulation of post-synaptic N-methyl-D-aspartate (NMDA) receptors and down-regulation of post-synaptic gamma-aminobutyric acid (GABA) receptors. A decrease in blood ethanol concentration due to abrupt cessation in alcohol consumption results in an imbalance between stimulatory (NMDA) and inhibitory (GABA) systems in the central nervous system. Excessive stimulatory effect leads to the development of the clinical signs and symptoms of AWS.

Question 5

How can you identify patients at risk of alcohol withdrawal on admission?

Answer 5

CAGE or SAD-Q (severity of alcohol dependence questionnaire)

C: Have you felt the need to cut down on your drinking?

A: Have you ever felt annoyed by someone criticising your drinking?

G: Have you ever felt bad or guilty about your drinking?

E: Have you ever had an eye-opener - a drink first thing in the morning to steady your nerves?

Question 6

List the symptoms of alcohol withdrawal syndrome.

Answer 6

4-24hrs since last drinks and:

• Anxiety
• Nausea and vomiting
• Autonomic dysfunction - Tremor, Tachycardia, Sweating, Palpitations
• Insomnia.
• Headache
• Tactile, visual, and auditory disturbances
• Blackouts, unexplained loss of consciousness, or
• Seizures - affect 10%
• Hallucinations - affect 25%; insects crawling on the skin or animals circling the bed

Check cognition, for head injury and for signs/symptoms of Wernicke’s encephalopathy.

Question 7

What are the clinical features of delirium tremens?

Answer 7

AWS left untreated → delirium tremens (5%) typically 48-72hrs after last drink

• Nightmares
• Confusion
• Disorientation
• Fever
• High blood pressure
• Heavy sweating
• Rapid heartbeat
• Chest pain
• Fatigue
• Nausea or vomiting
• Severe anxiety, similar to a panic attack
• Visual, auditory, and/or tactile hallucinations
• Uncontrollable tremors
• Seizures

Question 8

What are some risk factors for developing seizures in AWS and therefore warranting admission?

Answer 8

• A score >30 on SAD-Q
• Alcohol intake >30 units of alcohol per day
• Signs and symptoms of autonomic overactivity (e.g., tremor, tachycardia sweating, or palpitations)
• Signs of intoxication.

Question 9

What investigations would you do for AWS?

Answer 9

• VBG - hypochloraemia if vomiting
• Blood glucose - hypo common in those with alcohol dependence with poor nutrition. IF YOU GIVE GLUCOSE GIVE IT AT THE SAME TIME OR AFTER THIAMINE.
• FBC - high MCV indicates chronic alcohol use disorder, thrombocytopenia from splenomegaly
• U&Es - check for causes of life threatening arrhythmias e.g. hypomagnesaemia is common in chronic alcohol use
• LFTs - AST:ALT >2 in 70%, GGT is also high
• Ethanol - +ve
• Coagulation profile - INR and PT prolonged in CLD
• Bone profile - hypocalcaemia may occur due to hypomagnesaemia suppressing PTH; low vitamin D for many common reasons.

Consider:

• CT of head - e.g. if seizure, reduced GCS etc
• CXR - rules out concurrent illness which has led to a decrease in alcohol intake
• ECG - if tachycardic
• Amylase and lipase
• Ammonia - high in liver failure

Question 10

What are the differentials for AWS?

Answer 10

• Benzodiazepine withdrawal
• Sympathomimetic intoxication
• Wernicke’s encephalopathy
• Hypoglycaemia
• Opioid withdrawal
• Anticholinergic poisoning
• Thyrotoxicosis

Question 11

How do you manage AWS?

Answer 11

CIWA-Ar assessment - use this to guide treatment. Benzodiazepines usually used if scoring _>_10.

Benzodiazepines (e.g. chlordiazepoxide 50-100mg every 4-6hrs until agitation is controlled then max 300mg/day)

• Local guidelines dosing regimen e.g. fixed dose or symptom triggered. Usually fixed dose preferred as no risk of undertreating
• Reduce dose to zero over 7-10 days
• Titrate initial dose of medication to severity of dependence/regular consumption.
• e.g. Chlordiazepoxide 50-100mg 4-6hrly + PRN; rarely carbamazepine is used

Thiamine - give at least one intravenous dose of a high potency vitamin B preparation (e.g., Pabrinex® in the UK) to any patient who attends hospital with alcohol withdrawal

Seizure → lorazepam (short acting) + check BMs + refer to critical care

Question 12

On discharge of a patient managed for AWS, what advice should you give?

Answer 12

If discharged/self-discharged advise the patient to continue drinking alcohol. Stopping abruptly may lead to severe withdrawal.

• If possible, the patient should gradually reduce their intake over several weeks/months.
• It is common practice to advise them to decrease their level of drinking by not more than 25% every 2 weeks.

Question 13

What are the complications of AWS?

Answer 13

• Over sedation
• Delirium tremens (5%)
• Seizures
• Status epilepticus (less than 3% of AWS seizures progress to SE)
• Mortality

Question 14

What is the prognosis for AWS?

Answer 14

Alcohol withdrawal delirium is fatal in 15-20% if left untreated but early management reduces this to 1%

Patients may complain of persistent insomnia and autonomic symptoms for a few months after acute withdrawal phase. These symptoms usually last about 6 months.

About 50% of patients remain abstinent for a year.

Relapse prevention can be achieved by counselling strategies, self-help groups (e.g., Alcoholics Anonymous), and pharmacotherapy.

Question 15

What are the questions in the AUDIT questionnaire?

Answer 15

Question 16

How do you assess severity of alcohol withdrawal in a patient?

Answer 16

CIWA-Ar - scores _<_8 typically do not require medication for withdrawal.

Frequently treatment begins with benzodiazepines when CIWA-Ar scores reach 8-10, with standing or as needed dosing for scores 10-20. Some protocols even include transfer to the ICU for scores >20.