20th February 2024

Alcohol withdrawal and delirium tremens

Epidemiology, aetiology and pathophysiology

Up to 2-8% of patients who have alcohol-use disorders have symptoms suggestive of alcohol withdrawal, and this increases to 40-50% when looking at patients admitted to the Emergency department with trauma. Up to 25% of these patients have delirium tremens. 

Abrupt cessation of alcohol use is often implicated as the cause of alcohol withdrawal cessation. Alcohol acts as a CNS depressant by inhibiting excitatory (glutamate) receptors while enhancing inhibitory (GABA) receptors. Removal of alcohol results in overexcitation of the CNS system, leading to withdrawal symptoms and delirium tremens. 

Clinical presentation

Alcohol withdrawal symptoms exist within on a spectrum from mild symptoms up to delirium tremens. The patient usually presents with autonomic dysfunction, and symptom onset begins 6 hours after alcohol cessation. The condition’s progression depends on the overall amount of alcohol intake and period of alcohol dependence. 

Mild symptoms typically present with anxiety, headaches, palpitations and GI symptoms (nausea, vomiting). Patients can be seen pacing around due to anxiety and heightened awareness. Patients may also experience diaphoresis and tremors. 

Moderate symptoms typically include hallucinations and withdrawal seizures. Patients may experience auditory, tactile or visual hallucinations, which typically present 24-48 hours following cessation of alcohol. Seizures that occur in this context typically present as a generalised tonic-clonic seizure. The most severe presentation of alcohol withdrawal is delirium tremens. Delirium tremens is characterised by significant autonomic dysfunction with changes in vital observations. Patients typically experience tachycardia, hypertension, hyperthermia, agitation, diaphoresis, seizures and profound confusion. 

Investigation and treatment

The diagnosis of alcohol withdrawal depends on taking a good history from the patient and identifying the physical signs of alcohol withdrawal and co-morbidities secondary to alcohol use. The Clinical Institute for Withdrawal Assessment for alcohol revised scale (CIWA-Ar) is the tool used to help clinicians identify and stratify the severity of a patient’s alcohol withdrawal syndrome. The scoring system utilises the following symptoms as part of their scoring system: 

• Nausea and vomiting
• Tremor
• Sweats
• Anxiety
• Agitation
• Tactile disturbance
• Auditory disturbance
• Visual disturbance
• Headache/Fullness in the head
• Orientation

Points are given depending on the severity of each symptom, and a score is provided to indicate the severity of the withdrawal syndrome. Each hospital will have its cut-off for beginning treatment for alcohol withdrawal, and each clinician will refer to their local hospital guidance for the treatment threshold. A CIWA score of <8 typically represents mild symptoms, 9-15 for moderate symptoms and >15 for severe symptoms. 

The main goal of treatment is to control the patient’s autonomic dysfunction and reduce the risk of seizures. The mainstay of treatment for alcohol withdrawal is benzodiazepines. The choice of benzodiazepine is dependent on local guidance, but typically, diazepam and chlordiazepoxide are commonly used. This can be administered on a fixed schedule, or the patient’s symptom burden can guide this. Refractory alcohol withdrawal and seizures can be managed with phenobarbital and propofol, but this requires support in an intensive care setting. 

Basic supportive care for nutrition and hydration should also be provided. It is essential to watch for refeeding syndrome if there are suspicions that the patient may have had an inadequate diet for the days/weeks leading to readmission. Intravenous vitamin B complex is also given as a prophylaxis against Wernicke’s encephalopathy and patients are usually commenced on oral thiamine after completing their IV treatment. Follow-up with the substance misuse team, along with advice for abstinence from alcohol, should always be provided, and patients should be advised to reduce or stop their alcohol intake where possible. 

References

• Drummond, C. (2018). Alcohol-use disorder. Accessed on 2022 Mar 23. Available from: https://bestpractice.bmj.com/topics/en-gb/198. 
• Rahman A, Paul M. Delirium Tremens. [Updated 2021 Aug 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482134/ 
• Newman RK, Stobart Gallagher MA, Gomez AE. Alcohol Withdrawal. [Updated 2021 Nov 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441882/ 
• Hoffman, R., & Weinhouse, G. (2021 Nov 4). Management of moderate and severe alcohol withdrawal syndromes. Accessed on 2022 Mar 24. Available from: https://www.uptodate.com/contents/management-of-moderate-and-severe-alcohol-withdrawal-syndromes?topicRef=7809&source=see_link. 
• Holt, S., & Tetrault, J. (2020 Jan 10). Ambulatory management of alcohol withdrawal. Accessed on 2022 Mar 23. Available from: https://www.uptodate.com/contents/ambulatory-management-of-alcohol-withdrawal?topicRef=7809&source=related_link.