Alcohol Withdrawal



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



  • In 2019, 14.5 million Americans met the diagnostic criteria for alcohol use disorder (AUD). Approximately 50% of those with AUD have experienced AWS in their lifetime.
  • 32% of emergency room visits are alcohol related.

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

Risk Factors

  • Long duration of heavy alcohol consumption
  • Prior history of alcohol withdrawal episodes
  • Elevated blood pressure on presentation, comorbid medical conditions, or surgical illness
  • Physiological dependence on benzodiazepines (BZDs) or barbiturates

Geriatric Considerations
Elderly with AUD are more susceptible to withdrawal.

Pregnancy Considerations
Inpatient hospitalization for acute alcohol withdrawal management is recommended in pregnancy.

General Prevention

  • The U.S. Preventive Services Task Force recommends universal screening all adults.
  • The single screening question, “How many times in the past year have you had 5 or more (men) 4 or more (women) drinks in one day?” is the most sensitive and specific question for detecting unhealthy alcohol use.
  • Brief, standard assessment screening tools include CAGE, AUDIT, or AUDIT-C to detect unhealthy alcohol use.

Commonly Associated Conditions

  • General: weight loss and poor nutrition
  • Renal: electrolyte abnormalities (hyponatremia, hypokalemia, hypomagnesemia, hypophosphatemia)
  • GI: hepatitis, cirrhosis, esophageal varices, GI bleed, pancreatitis
  • Heme: thrombocytopenia, macrocytic anemia
  • Cardiovascular: hypertension, atrial fibrillation
  • CNS: seizures, hallucinations, memory deficits, atrophy, Wernicke-Korsakoff syndrome
  • Peripheral neuropathy
  • Pulmonary: aspiration pneumonitis; increased risk of anaerobic infections
  • Psychiatric: depression, posttraumatic stress disorder, bipolar disease, polysubstance use disorder
  • Reproductive: sexual dysfunction and amenorrhea

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