Nov 34 min read

Alcohol Withdrawal Syndrome (AWS) Management in Internal Medicine

Introduction

Alcohol Withdrawal Syndrome (AWS) is a potentially life-threatening condition that arises when a chronic alcohol user abruptly reduces or ceases alcohol intake. This syndrome manifests across a spectrum from mild symptoms, such as tremors and anxiety, to severe complications like seizures and delirium tremens (DTs). Early identification and systematic treatment are essential to mitigate the risks of severe complications and ensure a smooth withdrawal process.

Pathophysiology Overview

Chronic alcohol use induces adaptive changes in the central nervous system (CNS), leading to increased inhibitory neurotransmitter activity (e.g., GABA) and decreased excitatory neurotransmitter activity (e.g., NMDA). When alcohol intake stops, these adaptive changes lead to CNS hyperactivity due to an imbalance in inhibitory and excitatory signaling, resulting in the characteristic symptoms of AWS.

Clinical Presentation of AWS

AWS symptoms are categorized by their onset and severity:

Early Symptoms (6-24 hours post-alcohol cessation): Tremors, sweating, tachycardia, nausea, and mild anxiety.
Moderate Symptoms (24-48 hours): Agitation, fever, increased blood pressure, confusion, and hallucinations.
Severe Symptoms (48-72 hours): Risk of seizures and delirium tremens (DTs) characterized by altered mental status, autonomic instability, and visual/auditory hallucinations.

Diagnosis and Severity Assessment

The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) and the AWS score are the most widely used tools for assessing withdrawal severity and guiding treatment decisions.

CIWA-Ar Scoring System

The CIWA-Ar is a 10-item scale with each item rated on a scale from 0 to 7, covering symptoms like nausea, tremor, sweating, anxiety, hallucinations, and agitation. The cumulative score categorizes withdrawal severity:

0-8: Minimal Withdrawal
9-15: Moderate Withdrawal
≥16: Severe Withdrawal

Scores are used to guide pharmacologic intervention, with higher scores warranting more intensive treatment and monitoring.

Management of Alcohol Withdrawal Syndrome

Setting: Inpatient vs. Outpatient

Patients with mild withdrawal symptoms (AWS score 1-4) and no history of severe withdrawal or medical comorbidities can often be managed in an outpatient setting. However, moderate to severe cases (AWS score ≥5), especially those at risk for DTs, require inpatient management to ensure close monitoring and immediate intervention.

Pharmacologic Treatment Protocols

Benzodiazepines are the cornerstone of AWS management due to their ability to enhance GABAergic activity and reduce CNS hyperexcitability. Diazepam and Lorazepam are commonly used due to their efficacy and pharmacokinetic profiles.

1. Diazepam Protocol

Diazepam’s longer half-life provides sustained symptom relief, which is particularly beneficial in inpatient settings.

AWS Score	Severity	Diazepam Protocol
1-4	Mild	5 mg orally every 6-8 hours, up to 72 hours
5-9	Mild to Moderate	5-6 mg orally every 4 hours
10-14	Moderate to Severe	10-12 mg orally every 4 hours
≥15	Severe Withdrawal/DTs	20 mg orally or IV every 4 hours

Administration Note: Diazepam should be avoided in patients with severe liver impairment due to prolonged sedation risks. Monitor for respiratory depression and oversedation.

2. Lorazepam Protocol

Lorazepam, due to its shorter half-life and lack of hepatic metabolism, is preferred in patients with hepatic impairment or the elderly.

AWS Score	Severity	Lorazepam Protocol
1-4	Mild	1 mg orally every 6-8 hours, up to 72 hours
5-9	Mild to Moderate	1-2 mg every 4-6 hours
10-14	Moderate to Severe	2-3 mg orally every 4 hours
≥15	Severe Withdrawal/DTs	4 mg orally or IV every 4 hours

Clinical Tip: Reassess AWS scores every 4-6 hours during the acute phase to adjust benzodiazepine dosages accordingly.

Tapering and Monitoring

Once symptoms stabilize, benzodiazepine tapering should be considered. Gradually reduce the dose by 10-25% per day over 3-5 days to prevent rebound symptoms.

Adjunctive Therapies

Thiamine (Vitamin B1): Administer 100 mg IV daily for 3 days to prevent Wernicke's encephalopathy, a serious complication associated with chronic alcohol use.
Multivitamin Supplementation: Intravenous or oral multivitamins (including folate and B-complex) should be given to address potential nutritional deficiencies.
IV Fluids: Balanced crystalloid solutions (e.g., Ringer’s lactate or normal saline) are recommended to correct dehydration and electrolyte imbalances.

Supportive Care Measures

Nutritional Support: Patients with AWS often suffer from malnutrition; ensure a balanced diet rich in vitamins and minerals.
Monitoring: Frequent monitoring of vital signs, electrolyte levels, and blood glucose is essential, especially in patients with moderate to severe withdrawal.
Environmental Control: Reduce environmental stressors (low light, minimal noise) to prevent worsening agitation and autonomic instability.

Delirium Tremens (DTs): A Critical AWS Complication

DTs present in 5% of patients undergoing AWS, generally 48-72 hours post-alcohol cessation. Risk factors include prior episodes of DTs, high AWS scores, older age, and comorbid medical conditions.

DT Management Protocol

High-Dose Benzodiazepines: Diazepam or Lorazepam (10-20 mg IV every 4 hours) until symptoms stabilize.
Antipsychotics (adjunctive): Haloperidol (1-5 mg IV every 2-4 hours) may be used for agitation if benzodiazepines alone are insufficient.
IV Fluid Management: Avoid dextrose-containing solutions initially; however, 5% dextrose with thiamine may be given after initial stabilization.

Preventing Relapse: Post-Acute Care in AWS

Following the acute withdrawal period, referral to addiction specialists and community support programs (e.g., Alcoholics Anonymous) is crucial for sustained recovery. Medications such as Naltrexone, Acamprosate, or Disulfiram may be indicated as part of a comprehensive treatment plan to prevent relapse.

Naltrexone: 50 mg orally once daily, reduces cravings and the rewarding effects of alcohol.
Acamprosate: 666 mg orally three times daily, helps maintain abstinence by modulating neurotransmitter activity.
Disulfiram: 250 mg orally once daily; induces adverse effects when alcohol is consumed, discouraging alcohol intake.

Summary and Key Points for AWS Management

Identify and score AWS severity using CIWA-Ar or AWS scoring systems for accurate treatment planning.
Utilize benzodiazepine therapy tailored to AWS severity and patient-specific factors (e.g., liver function).
Administer adjunctive vitamins (e.g., thiamine) to prevent neuropsychiatric complications.
Implement environmental and supportive care to stabilize autonomic hyperactivity and reduce agitation.
Plan for long-term recovery by referring to support programs and considering relapse prevention medications.

Practical Takeaway

AWS management requires a systematic approach to ensure patient safety and mitigate complications. Clinicians should aim for comprehensive care that not only addresses the acute phase but also facilitates a long-term recovery pathway.