Acute Alcohol Withdrawal

How to Cite This Chapter: Holbrook AM. Acute Alcohol Withdrawal. McMaster Textbook of Internal Medicine. Kraków: Medycyna Praktyczna. https://empendium.com/mcmtextbook/chapter/B31.II.20.34..html Accessed August 07, 2020.
Last Updated: October 6, 2019
Last Reviewed: January 25, 2020
Chapter Information

DefinitionTop

Alcohol use disorder (AUD) is directly responsible for >7% of all premature deaths and is the third leading risk factor for death or disability globally. In 2015 in Canada, the number of hospitalizations directly related to alcohol-induced harm, including withdrawal, exceeded those due to myocardial infarction. Since AUD in North America and Europe has an estimated lifetime prevalence of 20% to 30%, a significant percentage of adults admitted to the hospital are at risk of acute alcohol withdrawal.

Clinical Features and DiagnosisTop

Acute alcohol withdrawal is defined by a constellation of clinical signs and symptoms associated with abrupt discontinuation or reduction of alcohol use after a period of heavy drinking. These symptoms and signs include:

1) Tremors, sweating, tachycardia, headache, light sensitivity, nausea, anxiety, and fidgeting.

2) In the case of more severe alcohol withdrawal, seizures, hallucinations (visual, auditory, or tactile), and delirium.

As other conditions can cause similar manifestations, it is important to consider, among others, sepsis, other drug intoxication, other psychiatric diagnoses, and hyperthyroidism.

TreatmentTop

The Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) is one of the best-known monitoring scales to diagnose alcohol withdrawal syndrome (AWS) and to measure the severity of alcohol withdrawal (Table 16.2-1). Once its interrater reliability was optimized, the scale has become an essential tool for gauging the need for treatment and for deciding which treatment to use. We have found that a structured order set has been highly effective at improving the management of AWS; the set includes:

1) Screening for AUD by asking how much alcohol the patient consumes.

2) History (time and date) of the patient’s last drink.

3) Blood alcohol concentration.

4) CIWA-Ar monitoring as frequent as hourly.

5) Thiamine administration for all patients.

6) High-dose benzodiazepine therapy in patients with a CIWA-Ar score ≥9.

This approach can reduce the incidence of delirium tremens and seizures by ~5 and ~8 cases per 100 patients, respectively, in comparison with placebo or other drugs.Evidence 1Moderate Quality of Evidence (moderate confidence that we know true effects of the intervention). Quality of Evidence lowered due to indirectness. Mayo-Smith MF. Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal. JAMA. 1997 Jul 9;278(2):144-51. PubMed PMID: 9214531.

Mild, Uncomplicated AWS (CIWA-Ar <9)

Treatment is aimed at reducing symptoms of alcohol withdrawal, so that the patient can focus on detoxification and addressing their AUD.

1. Usually it is sufficient to place the patient in dimly lit, peaceful surroundings. Pharmacologic treatment is not necessary.

2. Correct water and electrolyte disturbances, if present (see Electrolyte, Fluid, and Acid-Base Balance Disorders).

3. Administer thiamine 100 mg IV (preferred route) or orally for 3 days. There are no high-quality data to dictate dosing and duration. This dose is appropriate to prevent Wernicke encephalopathy. Higher doses (up to 500 mg tid for 5 days) have been suggested for the treatment of Wernicke encephalopathy.

4. Provide psychological support and frequent reorientation to the patient’s surroundings and circumstances.

5. As AWS resolves, patients should be referred for psychological therapy, such as cognitive behavioral therapy or other, aimed at ameliorating harmful drinking.

Moderate to Severe AWS (CIWA-Ar ≥9)

Although mortality from severe alcohol withdrawal is low, there is a risk of seizures, myocardial ischemia, aspiration, and delirium, that is, morbid events that prolong hospitalization. Aside from the components of the CIWA-Ar, the risk of AWS becoming severe may be increased by a history of delirium tremens, elevated gamma-glutamyl transferase (GGT) and aspartate aminotransferase (AST) levels, or low platelet counts. According to the Prediction of Alcohol Withdrawal Severity Scale (PAWSS), which is based on 8 history questions, blood alcohol level, and evidence of autonomic activity (available at mdcalc.com), the odds of developing severe AWS increase by >100 times if the score is ≥4.

1. Frequently monitor the patient’s clinical condition using the CIWA-Ar.

2. Correct water and electrolyte disturbances (see Electrolyte, Fluid, and Acid-Base Balance Disorders). Patients often present with considerable dehydration, hypokalemia, and hypomagnesemia. In the case of tachyarrhythmias, treatment with a beta-blocker may be indicated.

3. Administer thiamine 100 mg IV (preferred route) or orally. There are no high-quality data to dictate dosing and duration.

4. Use symptom-triggered replacement doses of a benzodiazepine (either diazepam 20 mg or lorazepam 4 mg orally) every hour up to 3 consecutive doses if the hourly CIWA-Ar score remains ≥9. After these 3 doses, the patient should be reassessed to make sure that the diagnosis of AWS is correct. Many patients with severe AWS will require >3 doses of a benzodiazepine. The symptom-triggered approach with full alcohol-replacing doses has been shown to be superior to fixed-schedule doses, causing resolution of AWS faster and with lower total drug doses administered.

5. Treatments that are specifically not recommended include alcohol (difficult to titrate, more adverse effects, psychologically inappropriate for AUD), antipsychotics (lower seizure threshold, inferior outcomes), nonbenzodiazepine anticonvulsants (inferior to benzodiazepines), and beta-blockers or baclofen (no evidence that they prevent seizures).

6. Brief interventions aimed to identify and counsel patients with a harmful drinking problem on the health effects of drinking have been shown to be effective. Once the symptoms have resolved, patients should be referred for psychological therapies to ameliorate harmful drinking and possibly offered drugs like acamprosate or naltrexone. Do not prescribe ongoing benzodiazepines, as the risk of addiction is high.

TablesTop

Table 16.2-1. The revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) Scale

Patient:

Date:

Time:

Heart rate:

Blood pressure:

Nausea and vomiting (observation)

0

None

1

Mild nausea and no vomiting

2

 

3

 

4

Intermittent nausea with dry heaves

5

 

6

 

7

Constant nausea, frequent dry heaves and vomiting

Tremor (observation; arms extended and fingers spread apart)

0

No tremor

1

Not visible but can be felt fingertip to fingertip

2

 

3

 

4

Moderate, with patient’s arms extended

5

 

6

 

7

Severe, even with arms not extended

Paroxysmal sweats (observation)

0

No sweat visible

1

Barely perceptible sweating, palms moist

2

 

3

 

4

Beads of sweat obvious on forehead

5

 

6

 

7

Drenching sweats

Anxiety (observation; ask the patient: “Do you feel nervous?”)

0

No anxiety, at ease

1

Mildly anxious

2

 

3

 

4

Moderately anxious, or guarded, so anxiety is inferred

5

 

6

 

7

Equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions

Agitation (observation)

0

Normal activity

1

Somewhat more than normal activity

2

 

3

 

4

Moderately fidgety and restless

5

 

6

 

7

Paces back and forth during most of the interview or constantly thrashes about

Tactile disturbances (observation; ask the patient: “Do you have any itching, pins and needles sensations, any burning, any numbness? Do you feel bugs crawling on or under your skin?”)

0

None

1

Very mild itching, pins and needles, burning, or numbness

2

Mild itching, pins and needles, burning, or numbness

3

Moderate itching, pins and needles, burning, or numbness

4

Moderately severe hallucinations

5

Severe hallucinations

6

Extremely severe hallucinations

7

Continuous hallucinations

Auditory disturbances (observation; ask the patient: “Are you more aware of sounds around you? Are they harsh? Do they frighten you? Do you hear anything that is disturbing you? Can you hear things you know are not there?”)

0

Not present

1

Very mild harshness or ability to frighten

2

Mild harshness or ability to frighten

3

Moderate harshness or ability to frighten

4

Moderately severe hallucinations

5

Severe hallucinations

6

Extremely severe hallucinations

7

Continuous hallucinations

Visual disturbances (observation; ask the patient: “Does the light appear to be too bright? Is its color different? Does it hurt your eyes? Can you see anything that is disturbing to you? Are you seeing things that you know are not there?)

0

Not present

1

Very mild sensitivity

2

Mild sensitivity

3

Moderate sensitivity

4

Moderately severe hallucinations

5

Severe hallucinations

6

Extremely severe visual hallucinations

7

Continuous hallucinations

Headache, fullness in head (observation; ask the patient: “Does your head feel different? Does it feel like there is a band around your head?”; do not rate for dizziness or light-headedness; otherwise, rate severity)

0

Not present

1

Very mild

2

Mild

3

Moderate

4

Moderately severe

5

Severe

6

Very severe

7

Extremely severe

Orientation and clouding of sensorium (observation; ask the patient: “What day is this? Where are you? Who am I?”)

0

Oriented and can do serial additions

1

Cannot do serial additions or is uncertain about date

2

Disoriented for date by ≤2 calendar days

3

Disoriented for date by >2 calendar days

4

Disoriented for place and/or person

The maximum possible score is 67 points.

Total CIWA-Ar score:

Rater’s initials:

Source: Br J Addict. 1989;84(11):1353-7.

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