Alcohol withdrawal syndrome (AWS) is a spectrum of symptoms resulting from an 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
- Long duration of heavy alcohol consumption
- Prior history of alcohol withdrawal episodes
- Elevated blood pressure on presentation, comorbid medical conditions or surgical illness
- Physiologic dependence on benzodiazepines (BZDs) or barbiturates
Elderly with AUD are more susceptible to withdrawal.
Inpatient hospitalization for acute alcohol withdrawal management is recommended in pregnancy.
- The U.S. Preventive Services Task Force recommends universal screening for 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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