Clinical management of alcohol withdrawal: A systematic review

Abstract

Alcohol withdrawal is commonly encountered in general hospital settings. It forms a major part of referrals received by a consultation-liaison psychiatrist. This article aims to review the evidence base for appropriate clinical management of the alcohol withdrawal syndrome. We searched Pubmed for articles published in English on pharmacological management of alcohol withdrawal in humans with no limit on the date of publication. Articles not relevant to clinical management were excluded based on the titles and abstract available. Full-text articles were obtained from this list and the cross-references. There were four meta-analyses, 9 systematic reviews, 26 review articles and other type of publications like textbooks. Alcohol withdrawal syndrome is a clinical diagnosis. It may vary in severity. Complicated alcohol withdrawal presents with hallucinations, seizures or delirium tremens. Benzodiazepines have the best evidence base in the treatment of alcohol withdrawal, followed by anticonvulsants. Clinical institutes withdrawal assessment-alcohol revised is useful with pitfalls in patients with medical comorbidities. Evidence favors an approach of symptom-monitored loading for severe withdrawals where an initial dose is guided by risk factors for complicated withdrawals and further dosing may be guided by withdrawal severity. Supportive care and use of vitamins is also discussed.

Alcohol withdrawal syndrome: mechanisms, manifestations, and management

“…Abrupt cessation of chronic alcohol consumption unmasks these changes with a glutamate‐mediated CNS excitation resulting in autonomic overactivity and neuropsychiatric complications such as delirium and seizures 10. The latter are usually of generalized tonic–clonic type and are mediated largely in the brainstem by abrogation of the tonic inhibitory effect of the GABAergic delta subunits 8.…”

“…During alcohol use, increase in dopamine positively influences the reward system thereby maintaining abuse. In withdrawal, increase in dopamine levels contributes to the clinical manifestations of autonomic hyperarousal and hallucinations 10, 11. Moreover, polymorphisms in the dopamine receptor 2 gene seem to influence not only AUD but also the clinical manifestation of alcohol withdrawal symptoms 12.…”

“…Physical examination and investigations should be directed toward detecting common signs and symptoms of AWS that are listed in Table 1 6, 10, 14, 15, 16, 17, 18…”

“…In minor withdrawal, patients always have intact orientation and are fully conscious. Symptoms start around 6 h after cessation or decrease in intake and last up to 4–48 h (early withdrawal) 6, 10. Hallucinations of visual, tactile or auditory qualities, and illusions while conscious are symptoms of moderate withdrawal.…”

“…They can last up to 6 d. The appearance of acute symptomatic seizures may emerge 6–48 h after the last drink 19. Delirium tremens (DT, onset 48–72 h after cessation of drinking) represents characteristics of severe withdrawal that may last for up to 2 weeks (late withdrawal) 6, 10, 15, 18. The chronological development of the various symptoms is illustrated in Fig.…”