Alcohol Withdrawal Syndrome

Alcohol Withdrawal Syndrome

1. Alcohol Withdrawal Syndrome Ade Wijaya, MD – February 2019

2. INtroduction Alcohol use disorder (AUD) was estimated to affect approximately 18% of the general population lifetime and 5 % annually Up to 50% of AUD patients experience withdrawal symptoms   A minority requires medical treatment Whiteman PJ, Hoffman RS, Goldfrank LR. Alcoholism in the emergency department: an epidemiologic study. Acad Emerg Med. 2000;7:14–20.   Saitz R. Clinical practice. Unhealthy alcohol use. N Engl J Med. 2005;352:596–607.   Hall W, Zador D. The alcohol withdrawal syndrome. Lancet. 1997;349:1897–1900.

3. Pathophysiology Acute alcohol ingestion produces CNS depression secondary to an enhanced GABAergic neurotransmission and to a reduced glutamatergic activity . The stimulation of GABA A   receptors and the inhibition of N-methyl-D-aspartate (NMDA ) receptors represents the most known mechanisms Chronic CNS exposure to alcohol produces adaptive changes in several neurotransmitter systems  tolerance Gaba receptors down regulation & NMDA receptors up regulation Mirijello A, D’Angelo C, Ferrulli A, Vassallo G, Antonelli M, Caputo F, Leggio L, Gasbarrini A, Addolorato G. Identification and management of alcohol withdrawal syndrome. Drugs. 2015 Mar 1;75(4):353-65.

4. Pathophysiology up-regulation of glutamate receptors α- amino-3-hydroxy-5-methylisoxazole-4-propionic acid (AMPA) and kainate has been described during AWS The abrupt reduction or cessation of alcohol intake produces an acute unbalance due both to the acute reduction of GABA activity and the increase of glutamatergic action, with consequent hyper excitability and development of AWS symptoms which may start as early as a few hours after the last alcohol intake The up-regulation of dopaminergic and noradrenergic pathways could be responsible for the development, respectively, of hallucinations and of autonomic hyperactivity during AWS “Kindling” is represented by an increased neuronal excitability and sensitivity after repeated episodes of AWS. “Kindling” has been proposed to explain the risk of progression of some patients from milder to more severe forms of AWS. Mirijello A, D’Angelo C, Ferrulli A, Vassallo G, Antonelli M, Caputo F, Leggio L, Gasbarrini A, Addolorato G. Identification and management of alcohol withdrawal syndrome. Drugs. 2015 Mar 1;75(4):353-65.

5. Symptoms Perry EC. Inpatient management of acute alcohol withdrawal syndrome. CNS Drugs. 2014;28:401–410. Bayard M, McIntyre J, Hill KR, et al. Alcohol withdrawal syndrome. Am Fam Physician.2004;69:1443–1450.

6. Risk factors for severe alcohol withdrawal syndrome Maldonado JR, Sher Y, Ashouri JF, et al. The “Prediction of Alcohol Withdrawal Severity Scale” (PAWSS): systematic literature review and pilot study of a new scale for the prediction of complicated alcohol withdrawal syndrome. Alcohol. 2014;48:375–390. Perry EC. Inpatient management of acute alcohol withdrawal syndrome. CNS Drugs. 2014;28:401–410

7. Diagnosis DSM-5 requires the observation of at least two of the following symptoms: autonomic hyperactivity (sweating or tachycardia ) increased hand tremor insomnia nausea or vomiting transient visual, tactile or auditory hallucinations or illusions psychomotor agitation anxiety tonic–clonic seizures 

8. Diagnosis < 8 : mild withdrawal 8–15 : moderate withdrawal (marked autonomic arousal ) > 15 : severe withdrawal; predictive of the development of seizures and delirium Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM. Assessment of alcohol withdrawal: the revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar). Br J Addict 1989;84:1353–7.

9. Diagnosis < 6: Mild AWS 6-9: moderate AWS > 9: severe AWS Wetterling T, Kanitz RD, Besters B, et al. A new rating scale for the assessment of the alcohol-withdrawal syndrome (AWS scale). Alcohol Alcohol. 1997;32:753–60

10. Kosten TR, O’Connor PG. Management of drug and alcohol withdrawal. N Engl J Med.2003;348:1786–1795.

11. SUMMARY Life threatening autonomic hyperactivity CIWA-Ar or Alcohol Withdrawal Scale Treatment: benzodiazepines