Alcohol withdrawal

Last updated: September 11, 2023

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.

Definitiontoggle arrow icon

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]

Clinical featurestoggle arrow icon

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]

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]

Classificationtoggle arrow icon

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.

Diagnosticstoggle arrow icon

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.

Managementtoggle arrow icon

Approach [2][8]

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


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

Lorazepam, Oxazepam, and Temazepam are preferred for individuals who drink a LOT (have alcoholic liver disease), because hepatic dysfunction does not have a strong effect on their metabolism. [9]Lorazepam, Oxazepam, and Temazepam are preferred for individuals who drink a LOT (have alcoholic liver disease), because hepatic dysfunction does not have a strong effect on their metabolism. All benzodiazepines are metabolized by the liver, but these three undergo biotransformation through glucuronidation, not CYP 450 activation, and are less affected by liver disease. [9]

Supportive care [2]

Do not delay glucose administration when indicated; evidence suggests that it is safe to administer glucose without prior thiamine supplementation. [2][11]

Risk and severity-based managementtoggle arrow icon

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 [12][13]

Different risk scores are used in clinical practice due to varying advantages and limitations. [14][15]

  • 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 [13]
Prediction of alcohol withdrawal severity scale (PAWSS) [16][17]
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]

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.
  • 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]

Severe (CIWA-Ar ≥ 19)


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).

Pharmacotherapy regimenstoggle arrow icon

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. [19][20]

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]

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Referencestoggle arrow icon

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