Understanding Alcohol Withdrawal: Types, Symptoms, and Treatment
Addiction Medicine • Emergency Medicine • Primary Care
Understanding Alcohol Withdrawal: Types, Symptoms & Treatment
Alcohol withdrawal ranges from mild symptoms to life‑threatening complications such as seizures and delirium tremens. Early identification, appropriate monitoring (e.g., CIWA‑Ar), benzodiazepine‑based treatment and supportive care significantly reduce morbidity and mortality. This guide summarises classifications, timelines, assessment tools and practical management steps for clinicians.
Pathophysiology in brief
Chronic alcohol use causes neuroadaptation with upregulation of excitatory NMDA receptors and downregulation of inhibitory GABAergic systems. Abrupt cessation removes GABAergic effects of alcohol, leading to central nervous system hyperexcitability manifesting as autonomic disturbance, tremor, seizures and potentially delirium tremens (DTs).
Types & typical timeline
| Feature | Timing after last drink | Notes |
|---|---|---|
| Minor withdrawal (mild) | 6–12 hours | Anxiety, tremor, insomnia, GI upset, headache |
| Alcohol withdrawal seizures | 6–48 hours | Generalised tonic–clonic seizures, often single or clustered |
| Alcoholic hallucinosis | 12–48 hours | Usually visual/auditory hallucinations with clear sensorium |
| Delirium Tremens (DTs) | 48–96 hours (can be later) | Confusion, agitation, marked autonomic instability, high mortality if untreated |
Common symptoms
- Tremor, anxiety, agitation, sweating, tachycardia, hypertension.
- Nausea, vomiting, headache and insomnia.
- Confusion, disorientation and hallucinations (visual commonly).
- Seizures—most commonly within first 48 hours.
Assessment & monitoring
- Use CIWA‑Ar scoring to quantify severity and guide benzodiazepine dosing (when feasible).
- Monitor vitals, fluid balance, electrolytes, blood glucose and liver function tests.
- Assess for co‑morbid conditions (head injury, infection, hepatic encephalopathy, hypoglycaemia).
- Obtain collateral history on quantity/frequency of alcohol use, prior withdrawals, seizures, and comorbid medications.
Treatment — pharmacologic
- Benzodiazepines (first‑line): chlordiazepoxide, diazepam or lorazepam — use symptom‑triggered dosing guided by CIWA‑Ar when possible; fixed‑dose regimens for severe or complicated patients.
- Seizure management: benzodiazepine for acute seizure control; consider loading with phenobarbital if refractory and consult neurology/ICU.
- Delirium Tremens: high‑dose benzodiazepines often required; adjunctive agents (phenobarbital, propofol) in ICU when benzodiazepine‑refractory.
- Thiamine: administer before glucose in all at‑risk patients (e.g., 200–300 mg IV daily initially) to prevent Wernicke’s encephalopathy.
- Other agents: antipsychotics (for severe agitation or psychosis) — use cautiously; beta‑blockers/clonidine for autonomic symptoms as adjuncts (not replacements for benzodiazepines).
Supportive care
- Hydration, correction of electrolytes (magnesium, potassium), and nutrition.
- Quiet, well‑lit environment; reorientation and reassurance for delirium or hallucinations.
- Prevent complications: aspiration precautions, fall prevention, DVT prophylaxis in immobilised patients.
Disposition — who needs admission
- Any patient with prior severe withdrawal, seizures, DTs or high CIWA‑Ar scores.
- Unstable vitals, severe comorbidity, delirium, or inability to safely home‑manage.
- Pregnancy, severe liver disease, or complex polysubstance use—consider specialised inpatient care.
Red flags — urgent escalation required
- Generalised tonic–clonic seizures or repeated seizures.
- Delirium with severe autonomic instability (fever, tachycardia, hypotension/hypertension).
- Worsening hypoxia or need for airway support.
- Suspected Wernicke’s encephalopathy (ophthalmoplegia, ataxia, confusion) — treat immediately with thiamine.
Case vignette
Patient: S., 52, heavy daily alcohol use (~200–300 g/day) admitted with tremor, sweating and CIWA‑Ar score 18. Management: symptom‑triggered lorazepam dosing, IV thiamine, electrolyte repletion and monitoring; no seizures occurred and S. stabilised over 5 days. Referred to inpatient addiction services for detox and relapse prevention.
தமிழில் — சுருக்கம்
மதுபானம் நீங்கும்போது உருவாகும் அறிகுறிகள் சிலர் நார்த்தனமாக, சிலர் உயிருக்கு ஆபத்தானவையாக இருக்கலாம். சீர் செய்யப்படாத திரவியம், பென்சோடியாஸிபைன்கள் மற்றும் தீர்மானமான கண்காணிப்பு அவசியம்.
Key takeaways
- Alcohol withdrawal varies in severity; use CIWA‑Ar where possible and prioritise benzodiazepine treatment for prevention of seizures and DTs.
- Always give thiamine to at‑risk patients before glucose; correct electrolytes and provide supportive care.
- Admit patients with prior severe withdrawal, high CIWA‑Ar, seizures, delirium or medical instability and link to addiction treatment services on stabilization.