Alcohol withdrawal

Question 1

Define alcohol withdrawal.

Answer 1

Alcohol withdrawal syndrome (AWS), commonly referred to as ‘the shakes’, occurs in patients with alcohol dependence when their daily alcohol consumption is decreased or stopped. The syndrome typically begins within 4 to 12 hours after the patient’s last drink, and may progress to potentially fatal delirium tremens.

Question 2

Explain the aetiology of alcohol withdrawal.

Answer 2

Chronic alcohol use results in up-regulation of postsynaptic NMDA receptors and down-regulation of post-synaptic GABA receptors. A decrease in blood ethanol concentration due to abrupt cessation in alcohol consumption results in an imbalance between stimulatory (NMDA) and inhibitory (GABA) systems in the central nervous system. Excessive stimulatory effect leads to the development of the clinical signs and symptoms of AWS.

Question 3

Explain the risk factors of alcohol withdrawal.

Answer 3

Risk factors include having a history of AWS or delirium tremens, as well as sudden withdrawal of alcohol.

Question 4

Summarise the epidemiology of alcohol withdrawal.

Answer 4

In the US, the 2016 National Survey on Drug Use and Health found that 5.2% of adults over 26 years, 10.7% of adults aged 18-25 years, and 2.0% of youths (aged 12 to 17 years) suffer from alcohol use disorder.
It is estimated that of these alcohol-dependent patients, approximately 50% will experience symptoms of alcohol withdrawal upon reduced alcohol intake.

Question 5

Recognise the presenting symptoms of alcohol withdrawal. Recognise the signs of alcohol withdrawal.

Answer 5

Hallucinations
Change in mental status
Tremor
Nausea and vomiting
Hypertension
Seizures

Question 6

Identify appropriate investigations for alcohol withdrawal and interpret the results.

Answer 6

Serum urea and creatinine
Liver function tests
Ethanol
Electrolyte panel
FBC
CT of head
CXR

Question 7

Generate a management plan for alcohol withdrawal.

Answer 7

Benzodiazepine or clomethiazole (+ supportive care)

Adjunct:
Phenobarbital
Vitamin supplementation

Question 8

Identify the possible complications of alcohol withdrawal and its management.

Answer 8

Over-sedation
Delirium tremens
Alcohol withdrawal seizures
Status epilepticus
Death

Question 9

Summarise the prognosis for patients with alcohol withdrawal.

Answer 9

Patients may complain of persistent insomnia and autonomic symptoms for a few months after acute withdrawal phase. These symptoms usually last about 6 months. About 50% of patients remain abstinent for a year.