Alcohol Withdrawal

Aka: Alcohol Withdrawal, Alcohol Withdrawal Syndrome, Alcohol Detoxification, Delirium Tremens

1. See Also
   1. Alcohol Dependence
   2. Alcohol Toxicity
   3. Alcohol Detoxification in Ambulatory Setting
   4. Alcoholism Management
   5. Chemical Dependency
   6. Drug Withdrawal
2. Epidemiology
   1. Duration: 5-7 days after abstinence
   2. Peak symptoms: 1-3 days after abstinence
3. Risk Factors: Severe withdrawal (Delirium Tremens)
   1. Age >40 years
   2. Heavy drinking >8 years
   3. Alcohol intake >100 grams, >1 pint liquor, >96 oz beer
   4. Patient experiences withdrawal symptoms when abstinent
   5. Hepatic Cirrhosis
   6. Lab abnormalities
      1. Mean Corpuscular Volume (MCV) increased
      2. Blood Urea Nitrogen (BUN) increased
      3. Blood Alcohol level >0.20 g/dl on random draw
   7. Reference
      1. Ferguson (1996) J Gen Intern Med 11:410-4
4. Symptoms
   1. Stage 1 symptoms (6-12 hours post-Alcohol)
      1. Anxiety or Panic Attacks
      2. Paresthesias, Shakes or Jitters
      3. Chills, Sweats, or Fevers
      4. Chest Pain or Palpitations
      5. Insomnia
      6. Headache
      7. Nausea or Vomiting
      8. Abdominal Pain
      9. Still coherent
   2. Stage 2 symptoms (24-72 hours post-Alcohol)
      1. Marked agitation, restlessness and diaphoresis
      2. Tremulous with constant eye movements
      3. Nausea, Vomiting, anorexia, and Diarrhea
      4. Sinus Tachycardia >120 bpm
      5. Systolic Hypertension with SBP >160 mmHg
      6. Confusion may be present
      7. Hallucinations (Alcoholic hallucinosis)
         1. Paranoid Delusions or illusions
         2. Auditory, visual, and tactile hallucinations
      8. Withdrawal Seizures (24-48 hours post-Alcohol)
         1. Generalized tonic-clonic Seizures
         2. Brief Seizures (<5 minutes) and may recur
         3. Status Epilepticus is not due to withdrawal
   3. Stage 3 symptoms (Delirium Tremens): 72-96 hours
      1. Visual hallucinations
      2. Disorientation and Delirium
      3. Severe Tachycardia and Hypertension
      4. Severe agitation and tremulousness
      5. Fever, severe diaphoresis
5. Signs
   1. Blood Pressure, pulse and temperature elevated
   2. Hyperarousal, Agitation, or Restlessness
   3. Cutaneous Flushing or Diaphoresis
   4. Dilated pupils
   5. Ataxia
   6. Altered Level of Consciousness or Disorientation
   7. Delirium Tremens
6. Complications: Delirium Tremens
   1. Head Trauma
   2. Myocardial Infarction
   3. Aspiration Pneumonia and other infections
   4. Electrolyte disturbance (e.g. Hypomagnesemia)
   5. Death
7. Management: General Measures
   1. Thiamine 100 mg PO qd
   2. Folate 1 mg PO qd
   3. Multivitamin qd
   4. Treat Hypomagnesemia if present
   5. Seizure precautions
8. Management: Special Circumstances
   1. Also see Alcohol Detoxification in Ambulatory Setting
   2. Benzodiazepine choice
      1. Valium and Librium offer lower risk of rebound
         1. Preferred in most cases for long half-life
      2. Seizure history: Valium
      3. Liver disease or elderly patient: Ativan or Serax
   3. Alternatives to Benzodiazepines: Carbamazepine
      1. Carbamazepine is effective in moderate withdrawal
         1. Malcolm (2002) J Gen Intern Med 17:349-55
      2. Dosing protocol
         1. Start at Carbamazepine (Tegretol) 800 mg on day 1
         2. Finish at Carbamazepine 200 mg on day 5
   4. Beta Blockers (Propranolol or Atenolol)
      1. Symptomatic relief of chills, shakes
      2. Improves vital signs
      3. Use selective Beta Blocker in Coronary Artery Disease
   5. Haloperidol
      1. Decreases agitation and hallucinations
      2. May lower Seizure threshold
9. Management: Symptom-Triggered Regimen (preferred)
   1. Preferred over protocol below
   2. Clinical Institute Withdrawal Assessment (CIWA-Ar)
      1. http://addiction-medicine.org/files/15doc.html
      2. Assess hourly to determine medication need
   3. Give one of following hourly until CIWA-Ar <8-10 points
      1. Librium 50 to 100 mg
      2. Valium 10 to 20 mg
      3. Ativan 2 to 4 mg
10. Management: Mild Alcohol Withdrawal Protocol
    1. Symptom-triggered protocol above is preferred
    2. General Protocol
       1. Diazepam (Valium) 5-10 mg PO prn or
       2. Lorazepam (Ativan) 1-2 mg PO q4-6h prn for 1-3 days
    3. Defining Criteria and Additional Medication Indications
       1. Systolic Blood Pressure > 150 mmHg
       2. Diastolic Blood Pressure > 90 mmHg
       3. Heart Rate > 100
       4. Temperature > 37.7 C (100 F)
       5. Tremulousness, Insomnia, or Agitation
11. Management: Moderate Alcohol Withdrawal Protocol
    1. Symptom-triggered protocol above is preferred
    2. General Protocol
       1. Diazepam (Valium)
          1. Day 1: 15 to 20 mg PO qid
          2. Day 2: 10 to 20 mg PO qid
          3. Day 3: 5 to 15 mg PO qid
          4. Day 4: 10 mg PO qid
          5. Day 5: 5 mg PO qid
       2. Lorazepam (Ativan)
          1. Days 1-2: 2-4 mg PO qid
          2. Days 3-4: 1-2 mg PO qid
          3. Day 5: 1 mg PO bid
       3. Librium 25-50 mg PO qid
          1. Decrease by 20% per day
    3. Defining Criteria and Additional Medication Indications
       1. Systolic Blood Pressure: 150-200 mmHg
       2. Diastolic Blood Pressure: 100-140 mmHg
       3. Heart Rate: 110-140
       4. Temperature: 37.7 to 38.3 C (100 to 101 F)
       5. Tremulousness, Insomnia, or Agitation
12. Management: Severe Alcohol Withdrawal Protocol
    1. Symptom-triggered protocol above is preferred
    2. Indicated in Delirium Tremens
    3. General Protocol (Requires ICU observation)
       1. Diazepam (Valium)
          1. Dose: 10-25 mg PO q1h prn while awake
          2. Endpoint: until adequate Sedation
       2. Lorazepam (Ativan)
          1. Dose: 1-2 mg IV q1h prn while awake for 3-5 days
          2. Endpoint: until adequate Sedation
       3. Librium
          1. Dose: 50 to 100 mg PO/IM/IV q4h (max: 300 mg/day)
          2. Endpoint: until adequate Sedation
    4. Defining Criteria and Additional Medication Indications
       1. Systolic Blood Pressure > 200 mmHg
       2. Diastolic Blood Pressure > 140 mmHg
       3. Heart Rate > 140
       4. Temperature > 38.3 C (101 F)
       5. Tremulousness, Insomnia, or Agitation
13. Resources: Patient Education
    1. Information from your Family Doctor: Alcohol Withdrawal
       1. http://www.familydoctor.org/handouts/007.html
14. References
    1. Bayard (2004) Am Fam Physician 69(6):1443-50
    2. Chang (2001) Med Clin North Am 85(5):1191-212
    3. Ferri (2001) Care of Medical Patient, p. 802-5
    4. McMicken in Marx (2002) Rosen Emergency Med, p. 2513-16