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Alcohol withdrawal syndrome

What's new

Added 2024 SAEM, 2023 CRISM, 2021 AAFP, 2020 ASAM, and 2019 SIA guidelines for the diagnosis and management of alcohol withdrawal syndrome.

Background

Overview

Definition
AWS is a condition that occurs after the abrupt cessation or significant reduction of alcohol intake following heavy and prolonged use.
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Pathophysiology
The pathophysiology of AWS involves neuroadaptive changes in the CNS due to chronic alcohol consumption. Chronic alcohol use leads to the upregulation of the excitatory neurotransmitter glutamate and the downregulation of the inhibitory neurotransmitter GABA. When alcohol consumption is abruptly stopped, this results in a hyperadrenergic state and increased glutamatergic activity, causing withdrawal symptoms.
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Disease course
The clinical course of AWS typically begins with mild symptoms, such as tremors, anxiety, and nausea within 6-12 hours of cessation of alcohol intake. More severe symptoms, such as hallucinations and seizures, can occur within 12-48 hours. Delirium tremens, characterized by severe confusion, hallucinations, and cardiovascular instability, typically occurs within 48-96 hours.
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Prognosis and risk of recurrence
Although most cases of AWS are self-limiting and resolve within a week, severe complications such as seizures and delirium tremens can be life-threatening. The use of validated risk assessment tools, such as the PAWSS, can help identify patients at risk of severe AWS and guide management strategies.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of alcohol withdrawal syndrome are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2024,2021), the American College of Gastroenterology (ACG 2024), the Society for Academic Emergency Medicine (SAEM 2024), the Canadian Research Initiative in Substance Misuse (CRISM 2023), the American Association for the...
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Screening and diagnosis

Indications for screening
As per ASAM 2020 guidelines:
Incorporate universal screening for unhealthy alcohol use into medical settings using a validated scale to identify patients with or at risk for alcohol use disorder and alcohol withdrawal.
Assess the risk of developing alcohol withdrawal in patients known to be using recent, regular, and heavy alcohol use, even in the absence of signs and symptoms.
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  • Diagnostic criteria

  • Differential diagnosis

Classification and risk stratification

Risk assessment: as per CRISM 2023 guidelines, Use clinical parameters, such as past seizures or delirium tremens, and the PAWSS to assess the risk of severe alcohol withdrawal complications and determine an appropriate withdrawal management pathway.
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Diagnostic investigations

Clinical assessment: as per ASAM 2020 guidelines, Assess the quantity, frequency, and last consumption time of alcohol in patients presenting with signs and symptoms suggestive of alcohol withdrawal to determine whether they are experiencing or at risk for developing alcohol withdrawal. Consider using a scale to screen for unhealthy alcohol use (such as the AUDIT-Piccinelli Consumption), acquiring information from collateral sources (such as family and friends), and obtain a laboratory test providing some measure of hepatic function for this assessment.
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  • Laboratory testing

  • Screening for comorbidities

Medical management

Setting of care, general principles
As per ASAM 2020 guidelines:
Decide on the level of care based on presenting signs and symptoms, risk for developing severe or complicated withdrawal or complications of withdrawal, and other factors such as recovery capital and environment.
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Consider using the ASAM Criteria Risk Assessment Matrix and withdrawal severity scales for determining the appropriate level of care for patients with AWS, recognizing that most withdrawal severity scales reflect current signs and symptoms and should not be used alone.
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  • Setting of care (outpatient)

  • Setting of care (inpatient)

  • Monitoring (outpatient)

  • Monitoring (intpatient)

  • Supportive care (outpatient)

  • Supportive care (inpatient)

  • Thiamine supplementation (outpatient)

  • Thiamine supplementation (inpatient)

  • Indications for pharmacotherapy (outpatient)

  • Indications for pharmacotherapy (inpatient)

  • Benzodiazepines

  • Anticonvulsants

  • Alpha-2 agonists

  • Other agents

  • Management of withdrawal seizure

  • Management of withdrawal delirium (monitoring)

  • Management of withdrawal delirium (general principles)

  • Management of withdrawal delirium (benzodiazepines)

  • Management of withdrawal delirium (other agents)

  • Management of alcohol-induced psychosis

  • Management of alcohol use disorder

Specific circumstances

Pregnant patients: as per ASAM 2020 guidelines, Consider offering inpatient management in all pregnant patients with alcohol use disorder requiring withdrawal management. Offer inpatient management in pregnant patients with at least moderate AWS (CIWA-Ar score ≥ 10).
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  • Patients with comorbidities

  • Patients with opioid use disorder

Patient education

General counseling: as per ASAM 2020 guidelines, Educate patients about the expected course of withdrawal, including common signs, symptoms, and treatment methods.
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Preventative measures

Prevention of AWS in the hospital: as per AAFP 2024 guidelines, Assess for alcohol withdrawal symptoms in all patients with alcohol use disorder at hospital admission and manage with benzodiazepines or phenobarbital.
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  • Prevention of AWS in the ICU

Follow-up and surveillance

Alcohol abstinence programs: as per CRISM 2023 guidelines, Offered ongoing alcohol use disorder care in all patients completing withdrawal management.
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