Alcohol Withdrawal is a clinical syndrome that occurs after sudden reduction or cessation of alcohol intake in individuals with alcohol dependence or prolonged heavy alcohol use.

The syndrome results from neuroadaptation caused by chronic alcohol exposure and may range from mild symptoms such as anxiety and tremors to severe complications including seizures and delirium tremens, which can be life-threatening.

Epidemiology

• Alcohol withdrawal commonly occurs among individuals with moderate to severe Alcohol Use Disorder who abruptly stop or reduce alcohol intake

• Severity varies depending on duration and quantity of alcohol use, previous withdrawal episodes, nutritional status, and comorbid medical conditions

• Severe withdrawal requires urgent medical management due to risk of seizures, delirium, and mortality

Risk Factors

• Long duration of heavy alcohol consumption

• Previous history of severe alcohol withdrawal

• Previous withdrawal seizures or delirium tremens

• Abrupt cessation of alcohol intake

• High daily alcohol consumption

• Poor nutritional status

• Coexisting medical illness

• Older age

• Concurrent substance use

Pathophysiology

Chronic alcohol use enhances inhibitory gamma-aminobutyric acid (GABA) activity and suppresses excitatory glutamate activity. The brain compensates by reducing GABA sensitivity and increasing glutamate activity. When alcohol intake suddenly stops, excessive excitatory neurotransmission occurs, leading to autonomic hyperactivity, anxiety, tremors, seizures, and altered mental status.

Clinical Presentation

Withdrawal symptoms usually begin within 6–24 hours after reducing or stopping alcohol intake.

Common Withdrawal Symptoms

• Insomnia

• Tremors

• Chills

• Anxiety

• Irritability

• Restlessness

• Sweating

• Nausea and vomiting

• Headache

• Palpitations

• Increased blood pressure

• Increased heart rate

Severe Withdrawal Symptoms

• Alcohol withdrawal seizures

• Hallucinations

• Severe agitation

• Confusion

• Delirium tremens

• Fever

• Severe autonomic instability

Diagnostic Criteria

Diagnosis is clinical and requires:

• Cessation of or reduction in heavy and prolonged alcohol use

• Development of characteristic withdrawal symptoms within hours to days after stopping or reducing alcohol intake

Withdrawal symptoms include:

• Insomnia

• Tremors

• Chills

• Anxiety

Additional features may include:

• Nausea or vomiting

• Autonomic hyperactivity

• Hallucinations

• Seizures

• Agitation

• Confusion

Differential Diagnosis

• Alcohol intoxication

• Delirium due to medical illness

• Drug withdrawal syndromes

• Hypoglycaemia

• Electrolyte abnormalities

• Head injury

• Infection causing delirium

• Psychiatric disorders

Investigations

Investigations help assess severity, detect complications, and identify comorbid conditions.

Laboratory Investigations

• Blood glucose

• Full blood count

• Serum electrolytes

• Renal function tests

• Liver function tests

• Serum magnesium

• Blood alcohol concentration where available

• Nutritional assessment

Additional Assessment

• Vital signs monitoring

• Mental status examination

• Assessment for seizure risk

• Assessment of risk of self-harm

• Screening for coexisting substance use

Management

Treatment Goals

• Prevent severe withdrawal complications

• Control withdrawal symptoms safely

• Correct nutritional deficiencies

• Prevent relapse

• Support long-term abstinence

Non-Pharmacological Management

• Provide supportive care in a safe environment

• Encourage participation in support groups that promote abstinence

• Provide psychoeducation regarding alcohol dependence and withdrawal

• Offer counselling and relapse prevention support

• Consider inpatient rehabilitation programmes where necessary

• Provide family support and involvement where appropriate

• Address social and psychological factors contributing to alcohol use

Pharmacological Management

Vitamin Supplementation

Thiamine 300 mg intramuscularly once daily.

Notes:

• Administer to prevent or treat neurological complications related to thiamine deficiency

• Give before glucose-containing fluids where possible in patients at risk of Wernicke encephalopathy

Management of Central Nervous System Symptoms

Diazepam 10 mg orally every 4–6 hours during the first 24 hours, then reduce the dose by 20% over 5 days.

Notes:

• Use only in inpatient care

• Dose should be adjusted according to severity of withdrawal symptoms

• Monitor for excessive sedation and respiratory depression

OR

Lorazepam orally according to clinical response.

Notes:

• May be preferred in patients with significant liver impairment because of shorter metabolism pathways

• Dose should be adjusted according to withdrawal severity

Relapse Prevention Following Detoxification

Naltrexone 50 mg orally once daily.

Notes:

• Dose should be titrated according to clinical response and tolerability

• Should be initiated after detoxification when the patient is medically stable

• Avoid in patients with acute hepatitis or severe liver impairment

• Combine with psychosocial interventions for better outcomes

Referral Criteria

Refer to the next level of care if:

• Severe alcohol withdrawal symptoms

• Withdrawal seizures

• Delirium tremens

• Severe agitation or confusion

• Reduced level of consciousness

• Significant medical complications

• Severe psychiatric comorbidity

• Failure of outpatient detoxification

• Need for inpatient rehabilitation

Complications

• Withdrawal seizures

• Delirium tremens

• Aspiration pneumonia

• Electrolyte abnormalities

• Wernicke encephalopathy

• Korsakoff syndrome

• Injury due to seizures or confusion

• Relapse to alcohol use

• Death

Prevention

• Early identification of Alcohol Use Disorder

• Planned medically supervised detoxification

• Nutritional support

• Access to counselling and rehabilitation services

• Long-term relapse prevention strategies

• Family and community support programmes

Prognosis

Most patients recover from mild withdrawal with appropriate supportive care. Severe withdrawal can be life-threatening but outcomes improve significantly with early recognition, benzodiazepine treatment, nutritional support, and continued relapse prevention care.

Patient Education

• Alcohol withdrawal can be dangerous and should not always be managed without medical supervision

• Do not stop heavy alcohol use suddenly without seeking medical advice

• Take prescribed medicines as directed

• Attend follow-up appointments and counselling sessions

• Avoid alcohol after detoxification to reduce relapse risk

• Seek urgent medical attention for seizures, confusion, hallucinations, or severe agitation