Alcohol withdrawal

Alcohol withdrawal (acute or imminent) should be suspected in any patient who is alcohol-dependent and has stopped or reduced their alcohol intake within hours or days of presentation.[1]National Institute for Health and Care Excellence. Alcohol-use disorders: diagnosis and clinical management of alcohol-related physical complications. April 2017 [internet publication]. https://www.nice.org.uk/guidance/cg100 [2]Royal College of Physicians. Alcohol dependence and withdrawal in the acute hospital. June 2012 [internet publication]. https://www.rcplondon.ac.uk/guidelines-policy/alcohol-dependence-and-withdrawal-acute-hospital [3]Bråthen G, Ben-Menachem E, Brodtkorb E, et al. Chapter 29: alcohol-related seizures. In: Gilhus NE, Barnes MP, Brainin M, eds. European handbook of neurological management. 2nd ed, vol 1. Oxford, UK: Blackwell publishing; 2011:429-36. https://www.eaneurology.org/fileadmin/user_upload/guidline_papers/EFNS_guideline_2011_Alcohol-related_seizures.pdf

Common symptoms are anxiety, nausea or vomiting, autonomic dysfunction, and insomnia.[1]National Institute for Health and Care Excellence. Alcohol-use disorders: diagnosis and clinical management of alcohol-related physical complications. April 2017 [internet publication]. https://www.nice.org.uk/guidance/cg100 [2]Royal College of Physicians. Alcohol dependence and withdrawal in the acute hospital. June 2012 [internet publication]. https://www.rcplondon.ac.uk/guidelines-policy/alcohol-dependence-and-withdrawal-acute-hospital [3]Bråthen G, Ben-Menachem E, Brodtkorb E, et al. Chapter 29: alcohol-related seizures. In: Gilhus NE, Barnes MP, Brainin M, eds. European handbook of neurological management. 2nd ed, vol 1. Oxford, UK: Blackwell publishing; 2011:429-36. https://www.eaneurology.org/fileadmin/user_upload/guidline_papers/EFNS_guideline_2011_Alcohol-related_seizures.pdf These may progress to severe withdrawal with seizures, and alcohol withdrawal delirium.[1]National Institute for Health and Care Excellence. Alcohol-use disorders: diagnosis and clinical management of alcohol-related physical complications. April 2017 [internet publication]. https://www.nice.org.uk/guidance/cg100 [2]Royal College of Physicians. Alcohol dependence and withdrawal in the acute hospital. June 2012 [internet publication]. https://www.rcplondon.ac.uk/guidelines-policy/alcohol-dependence-and-withdrawal-acute-hospital [3]Bråthen G, Ben-Menachem E, Brodtkorb E, et al. Chapter 29: alcohol-related seizures. In: Gilhus NE, Barnes MP, Brainin M, eds. European handbook of neurological management. 2nd ed, vol 1. Oxford, UK: Blackwell publishing; 2011:429-36. https://www.eaneurology.org/fileadmin/user_upload/guidline_papers/EFNS_guideline_2011_Alcohol-related_seizures.pdf

Identify any patient with features of severe alcohol withdrawal early. These patients need urgent treatment. Involve senior support and critical care. Alcohol withdrawal delirium is a life-threatening medical emergency requiring urgent treatment with a benzodiazepine. Patients having seizures also need urgent treatment with a benzodiazepine to reduce the likelihood of further seizures.

Not all patients with symptoms of alcohol withdrawal will need acute drug treatment; those with mild to moderate alcohol withdrawal symptoms can generally be managed with supportive care only.[3]Bråthen G, Ben-Menachem E, Brodtkorb E, et al. Chapter 29: alcohol-related seizures. In: Gilhus NE, Barnes MP, Brainin M, eds. European handbook of neurological management. 2nd ed, vol 1. Oxford, UK: Blackwell publishing; 2011:429-36. https://www.eaneurology.org/fileadmin/user_upload/guidline_papers/EFNS_guideline_2011_Alcohol-related_seizures.pdf Start a benzodiazepine regimen (fixed-dose or symptom-triggered depending on the clinical setting) for any patient needing acute drug treatment.[1]National Institute for Health and Care Excellence. Alcohol-use disorders: diagnosis and clinical management of alcohol-related physical complications. April 2017 [internet publication]. https://www.nice.org.uk/guidance/cg100 [2]Royal College of Physicians. Alcohol dependence and withdrawal in the acute hospital. June 2012 [internet publication]. https://www.rcplondon.ac.uk/guidelines-policy/alcohol-dependence-and-withdrawal-acute-hospital

Alcohol withdrawal occurs in patients who are alcohol-dependent and who have stopped or reduced their alcohol intake within hours or days of presentation.[1]National Institute for Health and Care Excellence. Alcohol-use disorders: diagnosis and clinical management of alcohol-related physical complications. April 2017 [internet publication]. https://www.nice.org.uk/guidance/cg100 [2]Royal College of Physicians. Alcohol dependence and withdrawal in the acute hospital. June 2012 [internet publication]. https://www.rcplondon.ac.uk/guidelines-policy/alcohol-dependence-and-withdrawal-acute-hospital [3]Bråthen G, Ben-Menachem E, Brodtkorb E, et al. Chapter 29: alcohol-related seizures. In: Gilhus NE, Barnes MP, Brainin M, eds. European handbook of neurological management. 2nd ed, vol 1. Oxford, UK: Blackwell publishing; 2011:429-36. https://www.eaneurology.org/fileadmin/user_upload/guidline_papers/EFNS_guideline_2011_Alcohol-related_seizures.pdf Symptoms typically begin 6 to 24 hours after the patient's last alcoholic drink, and may progress to life-threatening alcohol withdrawal delirium (also known as delirium tremens), with or without seizures.[2]Royal College of Physicians. Alcohol dependence and withdrawal in the acute hospital. June 2012 [internet publication]. https://www.rcplondon.ac.uk/guidelines-policy/alcohol-dependence-and-withdrawal-acute-hospital ​​[4]Parker AJ, Marshall EJ, Ball DM. Diagnosis and management of alcohol use disorders. BMJ. 2008 Mar 1;336(7642):496-501. http://www.ncbi.nlm.nih.gov/pubmed/18310004?tool=bestpractice.com [5]Reus VI, Fochtmann LJ, Bukstein O, et al. The American Psychiatric Association practice guideline for the pharmacological treatment of patients with alcohol use disorder. Am J Psychiatry. 2018 Jan 1;175(1):86-90. https://psychiatryonline.org/doi/pdf/10.1176/appi.books.9781615371969 http://www.ncbi.nlm.nih.gov/pubmed/29301420?tool=bestpractice.com [6]Hall W, Zador D. The alcohol withdrawal syndrome. Lancet. 1997 Jun 28;349(9069):1897-900. http://www.ncbi.nlm.nih.gov/pubmed/9217770?tool=bestpractice.com [7]Tiglao SM, Meisenheimer ES, Oh RC. Alcohol withdrawal syndrome: Outpatient management. Am Fam Physician. 2021 Sep 1;104(3):253-62. http://www.ncbi.nlm.nih.gov/pubmed/34523874?tool=bestpractice.com