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Alcohol withdrawal

Last updated: April 9, 2021

Summarytoggle arrow icon

Alcohol withdrawal syndrome (AWS) refers to the excitatory state that develops after a sudden cessation of or reduction in alcohol consumption following a period of prolonged heavy drinking. It is characterized by a variety of clinical features, including tremor, insomnia, anxiety, and autonomic instability. AWS is considered to be complicated if patients present with or develop alcohol withdrawal seizures, alcohol withdrawal delirium, or alcohol-induced psychotic disorder. AWS is a clinical diagnosis of exclusion based on characteristic symptoms in at-risk patients with recent reduction or cessation of alcohol consumption. Patients with AWS may also present with concomitant diseases that require treatment (e.g., alcoholic hepatitis, complicated cirrhosis) or develop AWS during periods of hospitalization for unrelated comorbidities. The management of uncomplicated and complicated AWS includes hydration, nutritional support, and thiamine to prevent or treat concomitant Wernicke encephalopathy, as well as pharmacological management with benzodiazepines and/or anticonvulsants to reduce symptoms and prevent disease progression and death. Most patients require hospital admission for monitoring and treatment.

A transient excitatory state caused by a sudden cessation of or reduction in alcohol consumption after a prolonged period of heavy drinking

References [1][2]

AWS is typically described as the progression through the stages of alcohol withdrawal, from minor to severe withdrawal with or without complicated disease. Not all patients progress through all of the stages of AWS, especially elderly patients and/or patients taking hypnotic or anxiolytic medications.

Alcohol withdrawal syndrome (uncomplicated) [2][3]

Alcohol withdrawal seizures [2][3]

  • Onset: : usually 8–48 hours after cessation of or reduction in alcohol consumption [2]
  • Clinical features

Withdrawal seizures may occur without prior significant features of AWS and may be the presenting symptom in some patients.

Alcohol-induced psychotic disorder (alcoholic hallucinosis) [2][3]

  • Onset: usually 12–24 hours after cessation of or reduction in alcohol consumption [2]
  • Clinical features
  • Duration: 24–48 hours after onset [2]

It may be challenging to distinguish alcoholic hallucinosis from the hallucinations associated with delirium; patients with delirium usually have impaired consciousness and abnormal vital signs.

Alcohol withdrawal delirium (delirium tremens) [2][3]

Classification by syndrome [1][2]

Classification by severity [4]

CIWA-Ar is the most common tool used to assess and classify alcohol withdrawal severity into the following categories: absent, mild, moderate, and severe.

Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) [2][4][5]
Symptoms Description
Minimal possible score (no symptoms) Maximal possible score (severe symptoms)
Nausea or vomiting

Absent (0)

Persistent nausea or vomiting (7)
Tremors Severe tremors (7)
Anxiety Acute panic (7)
Agitation Severe agitation (7)
Tactile disturbances Continuous hallucinations (7)
Auditory disturbances Continuous hallucinations (7)
Visual disturbances Continuous hallucinations (7)
Paroxysmal sweats Drenching sweat (7)
Headache Extremely severe (7)
Orientation Oriented and can do serial additions (0) Disoriented for person and/or place (4)

Interpretation (total combined score) [2]

  • Score 0–9: absent or mild withdrawal
  • Score 10–18: moderate withdrawal
  • Score ≥ 19: severe withdrawal

The CIWA-Ar is a useful tool to assess alcohol withdrawal severity that can help guide management and prevent complications in patients diagnosed with AWS.

Approach [2][3]

Patients with AWS often have other disorders that also require urgent identification and treatment (e.g., alcoholic hepatitis, sepsis, traumatic brain injury, Wernicke encephalopathy, decompensated liver cirrhosis).

Individuals with chronic alcohol use who are hospitalized often develop withdrawal symptoms 48–72 hours after admission because they do not have access to alcohol in the hospital. Consider screening admitted patients for alcohol use disorder using a validated tool (e.g., CAGE or AUDIT-C test).

Clinical diagnostic criteria [6]

DSM-5 diagnostic criteria for alcohol withdrawal syndrome
Fundamental criteria
Presence of ≥ 2 symptoms
Symptom characteristics
  • Produce significant distress or impairment (e.g., social, occupational)
  • Not attributable to or better explained by another medical or mental disorder

Additional investigations [2]

Laboratory findings in AWS are usually attributable to chronic alcohol use disorder and tend to be mild. Marked alterations should prompt suspicion for comorbid conditions.

Approach [2][8]

In the event of alcohol withdrawal seizures, benzodiazepines are preferred over other anticonvulsants to prevent further seizures.

Pharmacotherapy

See “Pharmacological treatment regimens for AWS” for detailed recommendations and dosages.

Lorazepam, Oxazepam, and Temazepam are preferred in those who drink a LOT because they have fewer active metabolites after hepatic metabolism; therefore they are safer for use in patients with alcoholic liver disease. [10][11]

Supportive care [2]

Do not delay glucose administration when indicated; evidence suggests that it is safe to administer glucose without prior thiamine supplementation. [2][13]

Risk assessment for alcohol withdrawal

Multifactorial risk assessment is recommended for patients on an individual basis.

Red flags for alcohol withdrawal [2][8]

The more red flags identified, the higher the risk of progression to severe or complicated AWS and failure of outpatient management. [2]

  • Patient characteristics
    • Age > 65 years
    • Significant medical comorbidities
    • Significant psychiatric comorbidities: e.g., active risk of suicide, psychosis.
    • Chronic, heavy drinking: e.g., positive AUDIT-C or CAGE
    • Low social supports and/or unsafe living environment
  • Related to the current withdrawal episode
    • Severe AWS: e.g. significant autonomic hyperactivity
    • Complicated AWS: e.g., seizures during the current withdrawal episode
    • Presence of AWS symptoms with detectable BAC
    • Additional acute illness
    • Significant abnormal laboratory results (see “Diagnostics”)
    • Simultaneous withdrawal from other substances or significant use of or dependence on other drugs
  • Related to previous withdrawal episodes

Validated risk scores [14][15]

Different risk scores are used in clinical practice due to varying advantages and limitations. [16][17]

  • CIWA-Ar: higher value as a severity score than a risk score.
    • Clinical applications
      • Establishing baseline severity
      • Monitoring of progression
      • Evaluating response to treatment
    • Limitations
      • Subjectivity in assessment parameters
      • Difficult to apply to uncommunicative or uncooperative patients
      • Less predictive of the risk of severe AWS, complicated AWS, or future withdrawal.
  • PAWSS score: greater predictive value to identify hospitalized patients at risk of complicated AWS [15]
Prediction of alcohol withdrawal severity scale (PAWSS) [18][19]
Features Score if present
Historical Within last 30 days Intoxication or drunkenness 1
Within last 90 days Co-ingestion of sedative-hypnotics 1
Co-ingestion of other substances of abuse 1
Any prior Alcohol withdrawal syndrome 1
Alcohol withdrawal seizures 1
Alcohol withdrawal delirium 1
Blackouts 1
Rehabilitation therapy for alcohol use disorder 1
Clinical Autonomic hyperactivity (e.g., agitation, heart rate > 120/min, tremor, diaphoresis, nausea) 1
Diagnostic BAC > 200 mg/dL at presentation 1

Management algorithm [2][8]

Most patients require inpatient management.

Management algorithm for alcohol withdrawal syndrome [2][3][4][8]
Severity

High-risk features

E.g., red flags for AWS, and/or PAWSS ≥ 4

Suggested initial pharmacotherapy Monitoring and disposition
Mild (CIWA-Ar < 10) Absent
  • Consider outpatient management
  • Monitor at least daily for 5 days after alcohol cessation.
Present
  • Consider inpatient monitoring in most cases.
  • Frequency should be based on individual evaluation.
    • CIWA-Ar ≥ 10 at any point during observation: Manage as moderate/severe withdrawal.
    • CIWA-Ar remains < 10 after 36 hours in patients with minimal high-risk features: Consider discontinuing monitoring.
Moderate (CIWA-Ar 10–18) Absent
  • Hospital admission is typically required.
  • First ∼ 24 hours: Monitor every 1–4 hours.
    • Patient remains symptomatic (e.g., CIWA-Ar ≥ 10)
    • Symptoms improving (e.g., CIWA-Ar < 10) for 24 hours: Taper down pharmacotherapy as tolerated and continue monitoring every 4–8 hours until discharge.
  • Consider ICU admission for: [4][5]
Present

Severe (CIWA-Ar ≥ 19)

Absent
Present

Monitor for signs of oversedation in all patients with AWS receiving pharmacological therapy.

Outpatient management of patients with moderate or severe alcohol withdrawal without red flags for AWS should only be considered if specialized centers and facilities for ambulatory monitoring are available, or if management can be provided by an experienced clinician. [2][8]

Management of complicated AWS [2]

Complications can occur at any point during withdrawal (e.g., upon presentation) and often necessitate escalation of the level of care (e.g., specialist or critical care consultation and high-dose pharmacotherapy). Follow local protocols if available.

These patients often require large doses of benzodiazepines, increasing the risk of oversedation and respiratory depression. Ensure that resuscitative equipment is readily available (e.g., bag-mask ventilation, supplemental O2, advanced airway devices).

Pharmacological treatment regimens for AWS [2][8]
Drug class Indications and rationale Sample agents and doses
Benzodiazepines Single-dose regimen for AWS
Front-loading dose for AWS
  • Patients with CIWA-Ar ≥ 10 and high risk of progression to severe or complicated AWS.
  • Administration of higher doses of benzodiazepines than in single-dose regimens for rapid control of severe symptoms
  • Continued monitoring is recommended (e.g., ICU care).
Symptom-triggered regimen for AWS
  • Patients with CIWA-Ar ≥ 10 and low risk of progression to severe or complicated AWS.
  • Repeat dosage depends on symptom severity (e.g., following changes in CIWA-Ar score).
Fixed-schedule regimen for AWS
  • Patients with CIWA-Ar ≥ 10 and high risk of progression to severe or complicated AWS.
  • Medication is administered at regular intervals and tapered down over the subsequent 5 days.
  • Can be combined with symptom-triggered regimens.
Anticonvulsants for AWS Alternative therapy for AWS
Adjunctive therapy for AWS

Hepatic impairment can cause the accumulation of benzodiazepines and their active metabolites. Consider preferentially using lorazepam, oxazepam, or temazepam in patients with liver disease to reduce the risk of oversedation. [10][11]

As a rule of thumb, the following doses of benzodiazepines are considered roughly equivalent in patients with normal hepatic function: diazepam 5 mg, chlordiazepoxide 25 mg, lorazepam 1 mg, and oxazepam 15 mg. [21]

  1. Alvanzo et al.. The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management. Journal of Addiction Medicine. 2020; 14 (3S): p.1-72. doi: 10.1097/adm.0000000000000668 . | Open in Read by QxMD
  2. Muncie HL Jr, Yasinian Y, Oge' L. Outpatient management of alcohol withdrawal syndrome.. Am Fam Physician. 2013; 88 (9): p.589-95.
  3. Eloma AS, Tucciarone JM, Hayes EM, Bronson BD. Evaluation of the appropriate use of a CIWA-Ar alcohol withdrawal protocol in the general hospital setting. Am J Drug Alcohol Abuse. 2017; 44 (4): p.418-425. doi: 10.1080/00952990.2017.1362418 . | Open in Read by QxMD
  4. Wood E, Albarqouni L, Tkachuk S, et al. Will This Hospitalized Patient Develop Severe Alcohol Withdrawal Syndrome?. JAMA. 2018; 320 (8): p.825. doi: 10.1001/jama.2018.10574 . | Open in Read by QxMD
  5. Knight E, Lappalainen L. Clinical Institute Withdrawal Assessment for Alcohol-Revised might be an unreliable tool in the management of alcohol withdrawal.. Can Fam Physician. 2017; 63 (9): p.691-695.
  6. Gray S, Borgundvaag B, Sirvastava A, Randall I, Kahan M. Feasibility and Reliability of the SHOT: A Short Scale for Measuring Pretreatment Severity of Alcohol Withdrawal in the Emergency Department. Academic Emergency Medicine. 2010; 17 (10): p.1048-1054. doi: 10.1111/j.1553-2712.2010.00885.x . | Open in Read by QxMD
  7. Maldonado JR, Sher Y, Das S, et al. Prospective Validation Study of the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) in Medically Ill Inpatients: A New Scale for the Prediction of Complicated Alcohol Withdrawal Syndrome. Alcohol and Alcoholism. 2015; 50 (5): p.509-518. doi: 10.1093/alcalc/agv043 . | Open in Read by QxMD
  8. Maldonado JR, Sher Y, Ashouri JF, et al. The “Prediction of Alcohol Withdrawal Severity Scale” (PAWSS): Systematic literature review and pilot study of a new scale for the prediction of complicated alcohol withdrawal syndrome. Alcohol. 2014; 48 (4): p.375-390. doi: 10.1016/j.alcohol.2014.01.004 . | Open in Read by QxMD
  9. Mirijello A, D’Angelo C, Ferrulli A, et al. Identification and Management of Alcohol Withdrawal Syndrome. Drugs. 2015; 75 (4): p.353-365. doi: 10.1007/s40265-015-0358-1 . | Open in Read by QxMD
  10. Jarvis, Carolyn. Physical examination & Health Assessment. Elsevier ; 2016
  11. SULLIVAN JT, SYKORA K, SCHNEIDERMAN J, NARANJO CA, SELLERS EM. Assessment of Alcohol Withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). Addiction. 1989; 84 (11): p.1353-1357. doi: 10.1111/j.1360-0443.1989.tb00737.x . | Open in Read by QxMD
  12. Schuckit MA. Recognition and Management of Withdrawal Delirium (Delirium Tremens). N Engl J Med. 2014; 371 (22): p.2109-2113. doi: 10.1056/nejmra1407298 . | Open in Read by QxMD
  13. Peppers MP. Benzodiazepines for alcohol withdrawal in the elderly and in patients with liver disease.. Pharmacotherapy. 1996; 16 (1): p.49-57.
  14. Ghabrial H, Desmond PV, Watson KJR, et al. The effects of age and chronic liver disease on the elimination of temazepam. Eur J Clin Pharmacol. 1986; 30 (1): p.93-97. doi: 10.1007/bf00614203 . | Open in Read by QxMD
  15. Sachdeva A, Choudary M, Chandra M. Alcohol Withdrawal Syndrome: Benzodiazepines and Beyond. J Clin Diagn Res. 2015; 9 (9). doi: 10.7860/jcdr/2015/13407.6538 . | Open in Read by QxMD
  16. Griffin et al.. Benzodiazepine pharmacology and central nervous system-mediated effects.. Ochsner J. undefined; 13 (2): p.214-23.
  17. Flannery AH, Adkins DA, Cook AM. Unpeeling the Evidence for the Banana Bag. Crit Care Med. 2016; 44 (8): p.1545-1552. doi: 10.1097/ccm.0000000000001659 . | Open in Read by QxMD
  18. Merlin M, Carluccio A, Raswant N, DosSantos F, Ohman-Strickland P, Lehrfeld D. Comparison of Prehospital Glucose with or without IV Thiamine. Western Journal of Emergency Medicine. 2011; 13 (5): p.406-409. doi: 10.5811/westjem.2012.1.6760 . | Open in Read by QxMD
  19. Detoxification and Substance Abuse Treatment. https://www.ncbi.nlm.nih.gov/pubmed/22514851. Updated: January 1, 2006. Accessed: June 3, 2020.
  20. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM–5). undefined. 2013 . doi: 10.1176/appi.books.9780890425596 . | Open in Read by QxMD
  21. Kasper DL, Fauci AS, Hauser SL, Longo DL, Jameson JL, Loscalzo J. Stroke. In: Kasper DL, Fauci AS, Hauser SL, Longo DL, Jameson JL, Loscalzo J, eds. Harrisons Manual of Medicine, 20th Edition. McGraw Hill Professional ; 2019.
  22. Acute Intoxication. http://www.who.int/substance_abuse/terminology/acute_intox/en/. Updated: January 1, 2017. Accessed: May 5, 2017.
  23. Semmens-Wheeler R, Dienes Z, Duka T. Alcohol increases hypnotic susceptibility. Conscious Cogn. 2013; 22 (3): p.1082-1091. doi: 10.1016/j.concog.2013.07.001 . | Open in Read by QxMD
  24. Ansstas G. Alcoholic Ketoacidosis. In: Khardori R, Alcoholic Ketoacidosis. New York, NY: WebMD. http://emedicine.medscape.com/article/116820. Updated: March 7, 2017. Accessed: October 7, 2017.
  25. Hoffman RS, Weinhouse GL. Management of Moderate and Severe Alcohol Withdrawal Syndromes. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/management-of-moderate-and-severe-alcohol-withdrawal-syndromes.Last updated: September 27, 2017. Accessed: December 9, 2017.
  26. Vij K. Textbook of Forensic Medicine & Toxicology: Principles & Practice. Elsevier Health Sciences ; 2014
  27. Cowan E, Su M. Ethanol Intoxication in Adults. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/ethanol-intoxication-in-adults.Last updated: September 7, 2016. Accessed: December 13, 2017.
  28. Burns MJ. Delirium Tremens (DTs). In: Pinsky MR, Delirium Tremens (DTs). New York, NY: WebMD. https://emedicine.medscape.com/article/166032. Updated: March 7, 2017. Accessed: December 13, 2017.
  29. Stern TA, Freudenreich O, Smith FA, Fricchione GL, Rosenbaum JF. Massachusetts General Hospital Handbook of General Hospital Psychiatry E-Book. Elsevier Health Sciences ; 2017
  30. Rasmussen SA, Smulian JC, Lednicky JA, Wen TS, Jamieson DJ. Coronavirus Disease 2019 (COVID-19) and pregnancy: what obstetricians need to know. Am J Obstet Gynecol. 2020 . doi: 10.1016/j.ajog.2020.02.017 . | Open in Read by QxMD
  31. Sarai M, Tejani AM, Chan AHW, Kuo IF, Li J. Magnesium for alcohol withdrawal. Cochrane Database of Systematic Reviews. 2013 . doi: 10.1002/14651858.cd008358.pub2 . | Open in Read by QxMD