alcohol withdrawal

alcohol withdrawal

Potentially life-threatening autonomic hyperactivity and CNS excitation following cessation of chronic alcohol intake. Management relies on risk stratification (PAWSS) and symptom-triggered benzodiazepines or phenobarbital.

pathophysiology

• Chronic State: Alcohol enhances GABA (inhibitory) and inhibits NMDA/Glutamate (excitatory) tone.
• Cessation: Abrupt removal leads to unopposed excitatory tone $\to$ autonomic instability, seizures, and delirium.

the kindling effect

Repeated cycles of intoxication and withdrawal lead to progressive neuroplastic changes (permanent upregulation of NMDA).

• Result: Each subsequent withdrawal episode becomes more severe and occurs after less alcohol consumption.
• Clinical Implication: A history of “mild shakes” years ago does not guarantee mild withdrawal now. Previous withdrawal seizures are the strongest predictor of future severe complications.

clinical timeline

phase	onset (approx.)	clinical features
Minor Withdrawal	6–12 hrs	Tremor (“shakes”), anxiety, headache, palpitations, GI upset.
Hallucinosis	12–24 hrs	Visual/tactile hallucinations. Patient remains oriented.
Seizures	12–48 hrs	Generalized tonic-clonic. Usually singular or short burst.
Delirium Tremens	48–96 hrs	Medical Emergency. Agitation, global confusion, disorientation, severe autonomic instability (fever, tachycardia, HTN). 5% mortality.

risk stratification

Do not rely on gestalt alone. Use the Prediction of Alcohol Withdrawal Severity Scale (PAWSS).

• PAWSS Score < 4 (Low Risk): Eligible for outpatient management (if social supports exist).
• PAWSS Score $\ge$ 4 (High Risk): Requires inpatient management (high risk of seizures/DTs).
• Red Flags for Admission: History of seizures/DTs (Kindling), concurrent acute illness, pregnancy, lack of housing/support.

management: inpatient (severe/high risk)

Standard of Care: Symptom-triggered therapy (CIWA-Ar) is superior to fixed-schedule dosing (reduced treatment duration and total dose).

1. assessment

• CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol, Revised). Goal: Maintain light somnolence/calm (CIWA < 8–10).

2. pharmacotherapy (benzodiazepines)

• Preferred: Diazepam (Valium).
  • Why: Long half-life + active metabolites = “auto-taper” effect (smoother withdrawal).
  • Dose: 10–20 mg PO q1h PRN until calm.
• Hepatic Impairment: Lorazepam (Ativan).
  • Why: No hepatic oxidation required (LOT: Lorazepam, Oxazepam, Temazepam).
  • Dose: 1–2 mg PO/SL/IV q1h PRN.

3. the phenobarbital protocol

emerging trend

Phenobarbital is gaining favour in ED/ICU settings due to mechanism offering strong control of acute hyperexcitability (GABA-A agonism + AMPA/Kainate antagonism) and its pharmacokinetics, but there is no evidence that it prevents the long‑term kindling phenomenon

• Pros: Long half-life (3–4 days), linear relationship between dose and serum levels, 100% bioavailability (PO/IV/IM).
• Evidence: 2023 Meta-analysis (Umar et al.) suggests efficacy in ICU settings, though evidence quality remains low/contradictory; requires strict protocol.
• Use: Often reserved for benzodiazepine-refractory withdrawal or as a loading dose strategy in ED.

management: outpatient (mild/low risk)

For PAWSS < 4 and stable social environment.

• First Line (Non-BZD): Gabapentin.
  • Evidence: Effective for mild withdrawal; reduces craving/anxiety.
  • Dose: Titrate to ~1200 mg/day over first few days, then taper.
• Alternatives: Carbamazepine or Clonidine (adjunct for autonomic symptoms only; does not prevent seizures).
• Benzodiazepines: Generally avoided in outpatient settings due to diversion/sedation risk, unless short strict course provided with daily dispensing.

supportive care & complications

• Thiamine (Vitamin B1):
  • Prophylaxis: 200 mg PO daily.
  • Suspected Wernicke Encephalopathy (WE): 200–300 mg IV/IM daily x 5 days.
  • Rule: Always give Thiamine before (or with) Glucose to prevent precipitating WE in malnourished patients.
• Electrolytes: Aggressively replete Magnesium, Potassium, and Phosphate.

  diagnosis check NOT always withdrawal. Keep wide DDx: Sepsis, subdural haematoma, hepatic encephalopathy, toxic alcohol ingestion.

  Altered LOC in an alcoholic patient is