Alcohol Withdrawal

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DESCRIPTION

Alcohol withdrawal syndrome (AWS) is a spectrum of symptoms resulting from abrupt cessation or reduction in alcohol intake, after a period of prolonged use. Presentation ranges from minor symptoms such as tremors and insomnia, to major complications such as seizures and delirium tremens (DT). Symptoms generally start within a few hours of the last drink and peak at 24 to 48 hours.

EPIDEMIOLOGY

Incidence

In the United States, about 10.2% of people ≥12 years old (~29 million individuals) have an alcohol use disorder (AUD) annually, based on the 2023 National Survey on Drug Use and Health (NSDUH).

ETIOLOGY AND PATHOPHYSIOLOGY

  • Consumption of alcohol stimulates γ-aminobutyric acid (GABA), resulting in decreased excitability with chronic ingestion; this repeated stimulation downregulates GABA inhibitory effects.
  • Concurrently, alcohol ingestion inhibits glutamate on the central nervous system (CNS), with chronic alcohol use upregulation of excitatory N-methyl-d-aspartate glutamate receptors.
  • When alcohol is abruptly stopped, the joint effect of a downregulated inhibitory system (GABA modulated) and upregulated excitatory system (glutamate modulated) results in brain hyperexcitability no longer suppressed by alcohol; clinically seen as AWS

Genetics

Several genes that may increase an individual’s susceptibility to AUD by affecting alcohol metabolism, brain chemistry, and reward systems. For example, the ADH1B gene which regulates the rate of liver metabolism of alcohol and the ALDH2 gene is involved with acetaldehyde metabolism, certain variants can cause a build-up of acetaldehyde, making drinking uncomfortable and potentially reducing the risk of AUD. Numerous other genes influence the brain’s sensitivity to alcohol’s effects (e.g., DRD2, OPRM1 genes).

RISK FACTORS

  • Long duration of heavy alcohol consumption
  • Recent binge-drinking behavior (NIAAA)
  • Prior history of alcohol withdrawal episodes
  • Elevated blood pressure on presentation, comorbid medical conditions, or surgical illness
  • Physiologic dependence on benzodiazepines (BZDs) or barbiturates

Geriatric Considerations
Older adults with AUD are more susceptible to withdrawal.Pregnancy Considerations
Inpatient hospitalization for acute alcohol withdrawal is recommended.

GENERAL PREVENTION

The U.S. Preventive Services Task Force recommends screening all adults for AUD.

  • Screening tools include CAGE, AUDIT, or AUDIT-C to detect unhealthy alcohol use.

COMMONLY ASSOCIATED CONDITIONS

With chronic AUD:

  • Electrolyte abnormalities
  • Cirrhosis, esophageal varices, GI bleed, pancreatitis
  • Macrocytic anemia
  • Hypertension, atrial fibrillation
  • Wernicke-Korsakoff syndrome

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