Alcohol Withdrawal Syndrome: Outpatient Management

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  • The relevance of this mechanism is highlighted by the fact that NMDA-receptor antagonists are highly effective anticonvulsants in animal models of alcohol withdrawal seizures (59).
  • This may be partly true in those who have developed dependence as they may experience withdrawal symptoms including autonomic arousal, hallucinations, seizures and delirium tremens (DT).
  • When not properly treated, AWS can progress to delirium tremens (Table 38–10).
  • Moderate symptoms include hallucinations and alcohol withdrawal seizures (rum fits) that can occur 12 to 24 hours after cessation of alcohol and are typically generalized in nature.
  • When you suddenly stop using that substance, your body goes through withdrawal symptoms as it adjusts to the absence of the addictive substance; this is why alcohol and seizures have a relationship with one another.
  • The hallmark of management for severe symptoms is the administration of long-acting benzodiazepines.

Unprovoked seizures that occur more than 48 hours after a person’s last drink may be due to another cause, such as head injury or withdrawal from other drugs. Seizures may occur in around 5% of people with alcohol withdrawal syndrome. It is possible for chronic alcohol consumption to cause seizures in people without a history of seizures. In some cases, excessive alcohol consumption may lead people to miss meals or medication, which can also make seizures more likely in people with epilepsy. Heavy drinking, particularly withdrawal from heavy drinking, may trigger seizures in those with epilepsy. Alcohol may also affect anti-seizure medications, which could trigger seizures.

How Should I Manage Alcohol If I Have Seizures Or Epilepsy?

ED clinicians are responsible for risk-stratifying patients with alcohol withdrawal syndrome under time and resource constraints, and must reliably identify those who are safe for outpatient management versus those who require more intensive levels of care [7]. Published clinical guidelines recommend stratifying patients with alcohol withdrawal based on their risk of developing complications (e.g., generalized tonic-clonic seizures and delirium tremens) [15–18]. These guidelines are largely limited to the primary care and outpatient settings and do not provide specific guidance for ED clinicians [15–17]. The STT was proposed by Saitz et al. in 1994[26] where in chlordiazepoxide was given when CIWA-Ar ratings were eight or more.

Benzodiazepines are also central nervous system depressants that work in the brain the same way as alcohol. They can ease many alcohol withdrawal symptoms, allowing your body to adjust slowly. However, benzodiazepines can also be addictive, so they should be taken alcohol withdrawal seizure with a doctor’s guidance. Chemical dependence is one of the most significant factors in your risk of experiencing dangerous withdrawal symptoms when you quit drinking. Alcohol dependence occurs after a period of consistent drinking or frequent binge drinking.

Alcohol Withdrawal Syndrome

We identified a lack of standardized definitions of alcohol withdrawal syndrome and severity among included studies. Studies also poorly reported detailed inclusion criteria, and/or clinical/patient information that would allow an interpretation of the populations most likely to benefit from each type of intervention. Although one recent literature review summarized evidence for ED withdrawal management, the authors extrapolated recommendations from guidelines for non-ED settings [19]. Another recent literature review also included evidence from non-ED studies [20]. Healthcare providers typically prescribe short-term medications to relieve the symptoms of mild to moderate alcohol withdrawal.

We used the Cochrane risk-of-bias tool for randomized trials Version 2 (RoB 2) to assess the risk of bias in the RCTs included in this study [29]. For non-randomized studies, we used the Cochrane risk of bias in non-randomized studies of interventions (ROBINS-I) tool [30]. Risk of bias assessments were performed by one trained reviewer (JK) and verified by the principal investigator (JM). In this rapid review, we adapted traditional systematic review methods to generate evidence within an accelerated time frame [21,22,23]. CIWA is a complex score which can be used to monitor and titrate therapy for alcohol withdrawal. CIWA scoring has several drawbacks, and generally isn’t very useful (especially within a critical care arena, which is staffed by experienced nurses).

Treatment and management

Approximately one-half of patients with alcohol use disorder who abruptly stop or reduce their alcohol use will develop signs or symptoms of alcohol withdrawal syndrome. The syndrome is due to overactivity of the central and autonomic nervous systems, leading to tremors, insomnia, nausea and vomiting, hallucinations, anxiety, and agitation. If untreated or inadequately treated, withdrawal can progress to generalized tonic-clonic seizures, delirium tremens, and death. The three-question Alcohol Use Disorders Identification Test–Consumption and the Single Alcohol Screening Question instrument have the best accuracy for assessing unhealthy alcohol use in adults 18 years and older. Two commonly used tools to assess withdrawal symptoms are the Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised, and the Short Alcohol Withdrawal Scale. Patients with mild to moderate withdrawal symptoms without additional risk factors for developing severe or complicated withdrawal should be treated as outpatients when possible.

A ceiling dose of 60 mg of diazepam or 125 mg of chlordiazepoxide is advised per day.[18] After 2-3 days of stabilization of the withdrawal syndrome, the benzodiazepine is gradually tapered off over a period of 7-10 days. Patients need to be advised about the risks and to reduce the dose, in case of excessive drowsiness. In in-patient settings where intense monitoring is not possible due to lack of trained staff, a fixed dose regimen is preferred. Alcohol dependence is a severe form of alcohol use disorder and it may first manifest when a person develops withdrawal symptoms after stopping alcohol – either due to family pressure, self-motivation, physical ill health or difficulty in procuring alcohol.