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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.
- 16 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
Some evidence for a genetic basis of AUD
- 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
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
Hospitalization or inpatient detoxification is usually required for treatment of acute alcohol withdrawal.
- 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.
- 3-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