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Alcohol withdrawal syndrome
Background
Overview
Definition
AWS is a condition that occurs after the abrupt cessation or significant reduction of alcohol intake following heavy and prolonged use.
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Pathophysiology
The pathophysiology of AWS involves neuroadaptive changes in the CNS due to chronic alcohol consumption. Chronic alcohol use leads to the upregulation of the excitatory neurotransmitter glutamate and the downregulation of the inhibitory neurotransmitter GABA. When alcohol consumption is abruptly stopped, this results in a hyperadrenergic state and increased glutamatergic activity, causing withdrawal symptoms.
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Risk factors
Risk factors for AWS include heavy and prolonged alcohol use, prior withdrawal episodes, concomitant use of other sedative-hypnotics, and comorbid medical or psychiatric conditions.
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Disease course
The clinical course of AWS typically begins with mild symptoms, such as tremors, anxiety, and nausea within 6-12 hours of cessation of alcohol intake. More severe symptoms, such as hallucinations and seizures, can occur within 12-48 hours. Delirium tremens, characterized by severe confusion, hallucinations, and cardiovascular instability, typically occurs within 48-96 hours.
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Prognosis and risk of recurrence
Although most cases of AWS are self-limiting and resolve within a week, severe complications such as seizures and delirium tremens can be life-threatening. The use of validated risk assessment tools, such as the PAWSS, can help identify patients at risk of severe AWS and guide management strategies. Patients requiring inpatient management are at higher risk of morbidity and require appropriate supportive care, including close monitoring, frequent reassurance, re-orientation to time and place, assessment of safety measures (such as falls and syncope), proper nutrition, folate and thiamine supplementation, and management of electrolyte disturbances (such as hypomagnesemia and hypophosphatemia). Intravenous glucose administration without thiamine supplementation carries a theoretical risk of worsening Wernicke's encephalopathy, as thiamine is required for carbohydrate metabolism; therefore, intravenous thiamine administration before glucose has been historically suggested. However, glucose delivery should not be delayed in nutritionally compromised patients.
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Guidelines
Key sources
The following summarized guidelines for the evaluation and management of alcohol withdrawal syndrome are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2024,2021), the American College of Gastroenterology (ACG 2024), the Society for Academic Emergency Medicine (SAEM 2024), the Canadian Research Initiative in Substance Misuse (CRISM 2023), the American Association for the ...
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Screening and diagnosis
Indications for screening
As per ASAM 2020 guidelines:
Incorporate universal screening for unhealthy alcohol use into medical settings using a validated scale to identify patients with or at risk for alcohol use disorder and alcohol withdrawal.
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Assess the risk of developing alcohol withdrawal in patients known to be using recent, regular, and heavy alcohol use, even in the absence of signs and symptoms.
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Diagnostic criteria
Differential diagnosis
Classification and risk stratification
Risk assessment: as per CRISM 2023 guidelines, use clinical parameters, such as past seizures or delirium tremens, and the PAWSS to assess the risk of severe alcohol withdrawal complications and determine an appropriate withdrawal management pathway.
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Prediction of Alcohol Withdrawal Severity Scale (PAWSS)
Calculator
When to use
Threshold criteria
Alcohol consumption in the last 30 days or a positive blood alcohol level on admission
Patient interview
Have been recently intoxicated or drunk in the last 30 days
Have experienced previous episodes of alcohol withdrawal
Have experienced withdrawal seizures
Have experienced delirium tremens
Have undergone alcohol rehabilitation treatment inpatient or outpatient treatment programs, or Alcoholics Anonymous attendance)
Have experienced blackouts
Have combined alcohol with other "downers" such as benzodiazepines or barbiturates) in the last 90 days
Have combined alcohol with any other substance of abuse in the last 90 days
Clinical evidence
Positive blood alcohol level on presentation
Evidence of increased autonomic activity heart rate > 120 bpm, tremor, sweating, agitation, nausea)
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Diagnostic investigations
Clinical assessment: as per ASAM 2020 guidelines, assess the quantity, frequency, and last consumption time of alcohol in patients presenting with signs and symptoms suggestive of alcohol withdrawal to determine whether they are experiencing or at risk for developing alcohol withdrawal. Consider using a scale to screen for unhealthy alcohol use (such as the AUDIT-Piccinelli Consumption), acquiring information from collateral sources (such as family and friends), and obtain a laboratory test providing some measure of hepatic function for this assessment.
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Alcohol Use Disorders Identification Test-Concise (AUDIT-C)
Calculator
When to use
How often did you have a drink containing alcohol in the past year?
Never
Monthly or less
2-3 times a month
2-3 times a week
≥ 4 times a week
How many drinks containing alcohol did you have on a typical day when you were drinking in the past year?
1 or 2 drinks
3 or 4
5 or 6
7 to 9
10 or more
How often did you have six or more drinks on one occasion in the past year?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
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Laboratory testing
Screening for comorbidities
Medical management
Setting of care, general principles
As per ASAM 2020 guidelines:
Decide on the level of care based on presenting signs and symptoms, risk for developing severe or complicated withdrawal or complications of withdrawal, and other factors such as recovery capital and environment.
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Consider using the ASAM Criteria Risk Assessment Matrix and withdrawal severity scales for determining the appropriate level of care for patients with AWS, recognizing that most withdrawal severity scales reflect current signs and symptoms and should not be used alone.
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Setting of care (outpatient)
Setting of care (inpatient)
Monitoring (outpatient)
Monitoring (inpatient)
Supportive care (outpatient)
Supportive care (inpatient)
Thiamine supplementation (outpatient)
Thiamine supplementation (inpatient)
Indications for pharmacotherapy (outpatient)
Indications for pharmacotherapy (inpatient)
Benzodiazepines
Anticonvulsants
Alpha-2 agonists
Other agents
Management of withdrawal seizure
Management of withdrawal delirium (monitoring)
Management of withdrawal delirium (general principles)
Management of withdrawal delirium (benzodiazepines)
Management of withdrawal delirium (other agents)
Management of alcohol-induced psychosis
Management of alcohol use disorder
Specific circumstances
Pregnant patients: as per ASAM 2020 guidelines, consider offering inpatient management in all pregnant patients with alcohol use disorder requiring withdrawal management. Offer inpatient management in pregnant patients with at least moderate AWS (CIWA-Ar score ≥ 10).
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Patients with comorbidities
Patients with opioid use disorder
Patient education
Preventative measures
Prevention of AWS in the hospital: as per AAFP 2024 guidelines, assess for alcohol withdrawal symptoms in all patients with alcohol use disorder at hospital admission and manage with benzodiazepines or phenobarbital.
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Prevention of AWS in the ICU