Alcohol Withdrawal

Question 1

Define

Answer 1

the symptoms that may occur when a person has been drinking too much alcohol on a regular basis and suddenly stops drinking.

Starts 10-72 hours after last drink

Question 2

Causes

Answer 2

• Enhances inhibitory GABA activity
• Inhibits excitatory glutamate neurotransmission

Chronic alcohol exposure results in a compensatory reduction in GABA receptor function and upregulation of glutamate NMDA receptors

Abrupt alcohol cessation leads to over-activation of the excitatory NMDA system relative to the GABA system

Question 3

Epidemiology

Answer 3

If untreated, 6% of alcohol-dependent patients

develop clinically relevant symptoms of withdrawal, with up to

10% of those experiencing delirium tremens

Question 4

Symptoms

Answer 4

Usually present ~8 hours after a significant fall in blood alcohol levels

• Nausea, sweating
• Restlessness, agitation, tremor, palpitations
• Insomnia, fatigue
• Visual hallucination
• Confusion
• Seizures
• Alcohol craving

Question 5

Signs

Answer 5

↑pulse, ↓BP

• Tremor
• Confusion
• Withdrawal seizures (generalised tonic clonic)
• Hallucinations (delirium tremens) – may be visual or
• tactile

Question 6

Investigations

Answer 6

Commonly used markers are ↑MCV, ↑GGT, ↑transaminases

Question 7

Management

Answer 7

Beware drops in BP - measure 4 hourly

Benzodiazepines are the recommended drugs for detoxification They have a slower onset of action and therefore are less likely to lead to abuse

• First 3 days → ChlordiazepoxideWean over 7 - 10 days (Alternatively diazepam)
• Vitamins may be needed → IV vitamin B complex (Pabrinex)
• Nutritional support may be required as often malnourished

Pay close attention to dehydration, electrolyte imbalance and infections

Acamprosate may help intense anxiety, insomnia, and cravingSide effects: D&V, ↓ or ↑libido

Disulfiram can be used to treat chronic alcohol dependence Causes acetaldehyde build-up (like metronidazole) with extremely unpleasant effects to any alcohol ingestion—e.g. flushing, throbbing headache, palpitations

Question 8

Complications

Answer 8

Patients can have seizures and die if it is left untreated

Question 9

Prognosis

Answer 9

Delirium tremens has a mortality of 35% if untreated

Mortality is < 2% with early detection and treatment