Alcohol Withdrawal

Alcohol Withdrawal – Treatment Options

Introduction
Alcohol withdrawal syndrome (AWS) occurs in individuals with chronic heavy alcohol use who abruptly reduce or stop drinking. It results from neuroadaptation: chronic alcohol enhances GABAergic inhibition and suppresses glutamatergic activity; sudden cessation causes CNS hyperexcitability. Symptoms range from mild tremors and anxiety to severe complications such as seizures, hallucinations, and delirium tremens (DTs). Management depends on severity and focuses on symptom control, complication prevention, and long-term abstinence support.

---

1. Assessment and Monitoring

• Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale used to grade severity.

• Continuous monitoring of vital signs, fluid balance, electrolytes, and mental status.

• Admit high-risk patients (history of DTs/seizures, severe comorbidities, advanced age).

---

2. Pharmacological Management

• Benzodiazepines (first-line):

  • Diazepam, chlordiazepoxide (long-acting) – preferred for smoother withdrawal.

  • Lorazepam, oxazepam (shorter-acting) – safer in elderly or liver disease.

  • Dosing strategies:

    • Symptom-triggered therapy (preferred): Administer based on CIWA-Ar score.

    • Fixed-schedule taper: Used when close monitoring is not possible.

• Adjunctive Medications:

  • Thiamine (100 mg IV/IM before glucose): Prevents Wernicke’s encephalopathy.

  • Multivitamins, folic acid.

  • Carbamazepine or gabapentin: May help in mild to moderate withdrawal when benzodiazepines are unsuitable.

  • Antipsychotics (e.g., haloperidol): For severe agitation or hallucinations, used cautiously alongside benzodiazepines.

---

3. Management of Complications

• Withdrawal seizures: Benzodiazepines are treatment of choice; phenytoin is ineffective unless underlying epilepsy exists.

• Delirium tremens (DTs):

  • Requires ICU-level care.

  • High-dose IV benzodiazepines (diazepam/lorazepam).

  • Supportive care: IV fluids, correction of electrolytes (Mg, K, PO4), cooling for hyperthermia.

---

4. Supportive and Environmental Care

• Quiet, well-lit, low-stimulation environment.

• Adequate hydration and electrolyte balance.

• Nutritional support (protein, vitamins, minerals).

• Frequent reassurance to reduce agitation and confusion.

---

5. Long-Term Management

• After stabilization, transition to relapse prevention therapy:

  • Naltrexone, acamprosate, or disulfiram (depending on patient profile).

• Referral to counseling, CBT, motivational interviewing, and support groups (AA).

• Address comorbid conditions such as depression, liver disease, and malnutrition.