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Alcohol Withdrawal

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Last Update: November 22, 2018.

Introduction

Alcohol withdrawal symptoms occur when patients stop drinking or significantly decrease their alcohol intake after a long-term dependence. Withdrawal has a broad range of symptoms from mild tremors to a condition called delirium tremens which results in seizures and could progress to death if not recognized and treated promptly.[1][2]

Etiology

Ethanol is the primary alcohol ingested by chronic users. It is a central nervous system (CNS) depressant that the body becomes reliant on over time.  It does this by inhibiting the excitatory portion (glutamate receptors) of the CNS and enhancing the inhibitory portions (GABA receptors) of the CNS. When the depressant is stopped, the central nervous system becomes overexcited as the inhibition is taken away. Thus, the body gets an excitatory overload which results in the symptoms of withdrawal.[3]

Pathophysiology

GABA (gamma-aminobutyric acid) is the major inhibitory neurotransmitter in the central nervous center. GABA has very specific binding sites available for ethanol thus increasing the inhibition of the central nervous system when present. Chronic ethanol exposure to GABA creates constant inhibition or depressant effects on the brain. Ethanol also binds to glutamate, which is one of the excitatory amino acids in the central nervous system. When it binds to glutamate, it inhibits the excitation of the central nervous system, thus worsening the depression of the brain.

History and Physical

Alcohol withdrawal can range from very mild symptoms to the severe form, which is named delirium tremens. The hallmark is autonomic dysfunction resulting from the excitation of the central nervous system. Mild signs/symptoms can arise within six hours of alcohol cessation. If symptoms do not progress to more severe symptoms within 24 to 48 hours, the patient will likely recover. However, the time to presentation and range of symptoms can vary greatly depending on the patient, their duration of alcohol dependence, and volume typically ingested. Most cases should be described by their severity of symptoms, not time since their last drink. Noting the last drink is very important however in any patient with an alcohol dependence history who may be presenting with other complaints. You can help prevent withdrawal by staying on top of this! Some features that may heighten your suspicion that a patient could suffer severe withdrawal include a history of prior delirium tremens as well as a history of low platelets (thrombocytopenia) or low potassium levels (hypokalemia).[4][5]

Mild symptoms can be insomnia, tremulousness, hyperreflexia, anxiety, gastrointestinal upset, headache, palpitations.

Moderate symptoms include alcohol withdrawal seizures (rum fits) that can occur 12 to 24 hours after cessation of alcohol and are typically generalized in nature. There is a 3% incidence of status epilepticus in these patients. About 50% of patients who have had a withdrawal seizure will progress to delirium tremens.

Delirium tremens is the most severe form of alcohol withdrawal, and its hallmark is that of an altered sensorium with significant autonomic dysfunction and vital sign abnormalities. It includes visual hallucinations, tachycardia, hypertension, hyperthermia, agitation, and diaphoresis. Symptoms of delirium tremens can last up to seven days after alcohol cessation and may last even longer.

These symptoms mimic those of withdrawal from long-term benzodiazepine or barbiturate use, so important historical features to note when a patient presents with autonomic dysfunction suspicious for a withdrawal syndrome should always include a medication list and social history. Also, consider these risk factors for any patient presenting with seizures of unknown etiology.

Evaluation

The diagnosis of alcohol withdrawal can be made by taking an excellent history and performing a thorough physical examination. It is a clinical diagnosis based on mild, moderate, or severe symptoms. Patients with suspicion for alcohol withdrawal should be evaluated for other underlying disease processes such as dehydration, infection, cardiac issues, electrolyte abnormalities, gastrointestinal bleeding, and traumatic injury. Basic laboratory studies (electrolytes, blood counts) may be drawn, but will likely be nondiagnostic. Many chronic alcoholics will have a baseline ketoacidosis due to their poor nutritional status, and labs may show acidemia with ketone production similar to a diabetic but with euglycemia or hypoglycemia due to lack of glycogen stores in their liver.[6][7][8]

Some literature recommends checking an alcohol level at the time of onset of symptoms as patients who are symptomatic while still having a positive alcohol level with symptoms of autonomic dysfunction/withdrawal will have a higher morbidity/mortality and their short-term prognosis can be poor.

Patients with prolonged altered sensorium or significant renal abnormalities should have an evaluation for the potential ingestion of another toxic alcohol. Patients who become financially strapped due to alcoholism could ingest other alcohols to become intoxicated. These can include isopropyl alcohol, commonly known as rubbing alcohol which can lead to acidemia without ketosis as well as hemorrhagic gastritis. Ethylene glycol (antifreeze) ingestion can lead to altered sensorium, seizures, and severe renal dysfunction with acidemia that may require initiation of hemodialysis. Methanol is rarely ingested as an ethanol substitute but can result in multisystem organ failure, blindness, and seizures.

Other common household substances can also contain a significant amount of alcohol if ingested in large quantities including mouthwash and cough syrup. Some of these items may also contain a lot of salicylates or acetaminophen so consider checking aspirin and acetaminophen levels in patients presenting with alcohol withdrawal.

Treatment / Management

Patients should be kept calm in a controlled environment to try to reduce the risks of progression from mild symptoms to hallucinations. With mild to moderate symptoms, patients should receive supportive therapy in the form of intravenous rehydration, correction of electrolyte abnormalities, and have comorbid conditions as listed above ruled out. Due to the risk of a comorbid condition called Wernicke-Korsakoff syndrome, patients can also receive a “banana bag” or cocktail of folate, thiamine, dextrose containing fluids, and a multivitamin.[9][10][11]

The hallmark of management for severe symptoms is the administration of long-acting benzodiazepines. The most commonly used benzodiazepines are intravenous diazepam (Valium) or intravenous lorazepam (Ativan) for management. Patients with severe withdrawal symptoms may require escalating doses and intensive care level monitoring. Early consultation with a toxicologist is recommended to assist with aggressive management as these patients may require benzodiazepine doses at a level higher than the practitioner is comfortable with to manage their symptoms.

Withdrawal seizures can typically be managed with benzodiazepines as well, but may require adjunct therapy with phenytoin, barbiturates, and may even require intubation and sedation with propofol (Diprivan), ketamine (Ketalar), or in the most severe cases dexmedetomidine (Precedex).

Oral chlordiazepoxide (Librium) and oxazepam (Serax) are very commonly used for prevention of withdrawal symptoms.

Toxic alcohol co-ingestions should be managed with the assistance of a toxicologist.

Pearls and Other Issues

Patients with a history of alcohol dependence may have confounding social or underlying psychiatric issues that you should also be aware of once they are stabilized. They will likely require a multidisciplinary approach before discharge.

Enhancing Healthcare Team Outcomes

Alcohol withdrawal symptoms usually appear when the individual discontinues or reduces the intake of alcohol after a period of prolonged consumption. In most cases, mild symptoms may start to develop within hours after the last drink, and if left untreated, can progress and become more severe. Because chronic alcohol use is very common in society, all healthcare workers including the nurse and pharmacist should be familiar with the symptoms of alcohol withdrawal and management. Today, pharmacotherapy is often used to manage the symptoms of alcohol withdrawal. If the encounter is as an outpatient, the patient should be referred for counseling. Prompt referral and treatment can help lower the morbidity of alcohol withdrawal symptoms and may even be lifesaving. [12][13]

Questions

To access free multiple choice questions on this topic, click here.

References

1.
Patigny P, Zdanowicz N, Lepiece B. How should psychiatrists and general physician communicate to increase patients' perception of continuity of care after their hospitalization for alcohol withdrawal? Psychiatr Danub. 2018 Nov;30(Suppl 7):409-411. [PubMed: 30439814]
2.
Egholm JW, Pedersen B, Møller AM, Adami J, Juhl CB, Tønnesen H. Perioperative alcohol cessation intervention for postoperative complications. Cochrane Database Syst Rev. 2018 Nov 08;11:CD008343. [PMC free article: PMC6517044] [PubMed: 30408162]
3.
Finn DA, Helms ML, Nipper MA, Cohen A, Jensen JP, Devaud LL. Sex differences in the synergistic effect of prior binge drinking and traumatic stress on subsequent ethanol intake and neurochemical responses in adult C57BL/6J mice. Alcohol. 2018 Sep;71:33-45. [PubMed: 29966824]
4.
Chhatlani A, Farheen SA, Manikkara G, Setty MJ, DeOreo E, Tampi RR. Anticonvulsants as monotherapy or adjuncts to treat alcohol withdrawal: A systematic review. Ann Clin Psychiatry. 2018 Nov;30(4):312-325. [PubMed: 30372509]
5.
Hui D. Benzodiazepines for agitation in patients with delirium: selecting the right patient, right time, and right indication. Curr Opin Support Palliat Care. 2018 Dec;12(4):489-494. [PMC free article: PMC6261485] [PubMed: 30239384]
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Pikovsky M, Peacock A, Larney S, Larance B, Conroy E, Nelson E, Degenhardt L. Alcohol use disorder and associated physical health complications and treatment amongst individuals with and without opioid dependence: A case-control study. Drug Alcohol Depend. 2018 Jul 01;188:304-310. [PubMed: 29807218]
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Ezard N, Cecilio ME, Clifford B, Baldry E, Burns L, Day CA, Shanahan M, Dolan K. A managed alcohol program in Sydney, Australia: Acceptability, cost-savings and non-beverage alcohol use. Drug Alcohol Rev. 2018 Apr;37 Suppl 1:S184-S194. [PubMed: 29665174]
8.
Günthner A, Weissinger V, Fleischmann H, Veltrup C, Jäpel B, Längle G, Amann K, Hoch E, Mann K. [Health Care Organization - The New German S3-Guideline on Alcohol-Related Disorders and its Relevance for Health Care]. Rehabilitation (Stuttg). 2018 Oct;57(5):314-320. [PubMed: 29359282]
9.
Campbell EJ, Lawrence AJ, Perry CJ. New steps for treating alcohol use disorder. Psychopharmacology (Berl.). 2018 Jun;235(6):1759-1773. [PubMed: 29574507]
10.
Mo Y, Thomas MC, Laskey CS, Shcherbakova N, Bankert ML, Halloran RH. Current Practice Patterns in the Management Of Alcohol Withdrawal Syndrome. P T. 2018 Mar;43(3):158-162. [PMC free article: PMC5821243] [PubMed: 29491698]
11.
Masood B, Lepping P, Romanov D, Poole R. Treatment of Alcohol-Induced Psychotic Disorder (Alcoholic Hallucinosis)-A Systematic Review. Alcohol Alcohol. 2018 May 01;53(3):259-267. [PubMed: 29145545]
12.
Sullivan SM, Dewey BN, Jarrell DH, Vadiei N, Patanwala AE. Comparison of phenobarbital-adjunct versus benzodiazepine-only approach for alcohol withdrawal syndrome in the emergency department. Am J Emerg Med. 2018 Oct 11; [PubMed: 30414743]
13.
Manning V, Garfield JBB, Campbell SC, Reynolds J, Staiger PK, Lum JAG, Hall K, Wiers RW, Lubman DI, Verdejo-Garcia A. Protocol for a randomised controlled trial of cognitive bias modification training during inpatient withdrawal from alcohol use disorder. Trials. 2018 Nov 01;19(1):598. [PMC free article: PMC6211457] [PubMed: 30382877]
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Bookshelf ID: NBK441882PMID: 28722912

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