Acute Alcohol Withdrawal and Delirium Tremens

This article focuses specifically on acute alcohol withdrawal and delirium tremens. NICE is currently working on guidelines for the clinical management of alcohol use disorders which are expected to cover the clinical management of acute alcohol withdrawal. These guidelines should be published in 2010.

There are several related articles on alcoholism and alcohol related problems.

• Only about 50% of alcohol-dependent patients develop clinically relevant symptoms of withdrawal.^1,2
• Less than 1 in 20 people who are alcohol-dependent have a grand mal seizure during withdrawal (usually on day 2), or severe agitated confusion (delirium tremens).³

Acute alcohol withdrawal can be a complex issue. Some patients have mild symptoms and can be managed in the community; others have more severe symptoms or a history of adverse outcomes and need close inpatient supervision.⁴

Problems associated with alcohol withdrawal can include:⁴

• Uncomfortable withdrawal symptoms
• Delirium tremens
• The Wernicke-Korsakoff syndrome
• Seizures
• Depression
• Polysubstance abuse
• Electrolyte disturbances
• Complications due to associated liver disease

Presentation

• This may be in a number of different ways:
  • A patient may present in acute alcohol withdrawal.
  • A patient may be admitted to hospital for another reason and thus an unplanned alcohol withdrawal may be precipitated. Alcohol-use disorders can complicate the assessment and treatment of other medical and psychiatric problems.³
  • A patient may present wishing to abstain from alcohol but be seen as at risk of acute alcohol withdrawal.
• Withdrawal symptoms:
  • Symptoms typically present about 8 hours after a significant fall in blood alcohol levels. They peak on day 2 and, by day 4 or 5, the symptoms have usually improved significantly.^2,3
  • Minor withdrawal symptoms (can appear 6-12 hours after alcohol stopped):^5,6,7
    • Insomnia and fatigue
    • Tremor
    • Mild anxiety/feeling nervous
    • Mild restlessness/agitation
    • Nausea and vomiting
    • Headache
    • Excessive sweating
    • Palpitations
    • Anorexia
    • Depression
    • Craving for alcohol
  • Alcoholic hallucinosis (can appear 12 to 24 hours after alcohol stopped):⁵
    • Includes visual, auditory, or tactile hallucinations
  • Withdrawal seizures (can appear 24 to 48 hours after alcohol stopped):⁵
    • These are generalised tonic-clonic seizures
  • Alcohol withdrawal delirium or 'delirium tremens' (can appear 48 to 72 hours after alcohol stopped). ⁵ See below.

History

Ask about:

• Quantity of alcoholic intake and duration of alcohol use.
• Time since last drink.
• Whether previous alcohol withdrawals have been attempted.
• Medical history including psychiatric history.
• Drug history (including prescribed drugs and drugs of abuse and any drug allergies).
• Support network.

Note that many patients may not actually be trying to stop drinking. They may either have an intercurrent illness stopping them from drinking or problems with alcohol availability.

Management of alcohol withdrawal

• Most people with alcohol dependence can undergo medically assisted withdrawal safely at home, after risk assessment.⁷
• Features indicating a high risk of complicated withdrawal where admission to hospital is suggested include:⁷
  • Severe dependence
  • Previous delirium tremens
  • Previous alcohol withdrawal seizures
  • Previous failed detoxification(s) in the community
  • Poor support at home
  • Cognitive impairment
• Other features that require further assessment and will depend on the level of community support available before suitability for community detoxification can be determined include:⁷
  • Acute or chronic physical illness (e.g. infection and diseases of the liver, cardiovascular system, or respiratory system)
  • Acute or chronic mental health problems (e.g. suicidal ideation, depression, anxiety, psychosis, or acute distress)
  • Malnutrition
  • Self-neglect
  • Older age
• Clinical Knowledge Summaries also suggests that if there is dependence on benzodiazepines or active misuse of other drugs, specialist advice should be sought before attempting primary care detoxification.⁶

• SIGN guidelines for the management of harmful drinking and alcohol dependence in primary care suggest that medication may not be needed for detoxification if:⁸
  • A male patient is drinking < 15 units/day or a female patient is drinking < 10 units/day AND they do not report any recent withdrawal symptoms or recent drinking to prevent withdrawal symptoms.
  • The patient has no alcohol on breath test and no withdrawal signs or symptoms.
• A scale has also been suggested to assess the severity of the alcohol withdrawal syndrome: the revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar).⁹ A link can be found below.

1. Explain the symptoms of withdrawal and try to advise on how to cope with these.
2. Advise the patient that delirium, confusion, seizures, falls, severe nausea or vomiting, and high levels of distress need urgent medical attention and may mean admission to hospital is necessary.
3. Encourage a friend/relative to act as support, round-the-clock if possible. If this is not possible, home visits from a medical practitioner are desirable. Having some activities to do where possible can also help.
4. Ensure that there is adequate provision for time off work/childcare.
5. Contact details for whom to call if there is a problem should be provided.
6. Prescribe appropriate medication.

Benzodiazepines:

• These are the recommended drugs for detoxification. They have a slower onset of action and therefore are less likely to lead to abuse.¹⁰
• A reducing dose of chlordiazepoxide over 5-7 days is commonly used.
• Ideally see the patient daily and dispense the medication daily.
• Diazepam is an alternative and is available to prescribe on a blue FP10MDA-SS form.⁶
• You can check for alcohol on the breath, or use a breathalyser to confirm that the patient is abstinent.
• Stop the benzodiazepine once detoxification is complete or if the patient relapses and starts drinking again during detoxification.
• An example of a reducing dose regimen for chlordiazepoxide is given in the CKS reference below.
• A recent BMJ review has suggested the following regimen for moderate alcohol dependence in the community or as an inpatient:⁷
  • Day 1: 20 mg chlordiazepoxide four times daily
  • Day 2: 15 mg chlordiazepoxide four times daily
  • Day 3: 10 mg chlordiazepoxide four times daily
  • Day 4: 5 mg chlordiazepoxide four times daily
  • Day 5: 5 mg chlordiazepoxide twice daily
• Dose depends on factors including level of alcohol dependence, sex, weight, current liver function. Smaller doses may be needed for mild dependence and larger doses for severe dependence. People at high risk of seizures or delirium tremens may need a longer period of treatment (maximum of two weeks).⁷
• For mild/moderate alcohol detoxification in secondary care, some hospitals have a system whereby regular reducing doses of chlordiazepoxide are not given due to concerns about sedative effects. They have a point score where nurses regularly make an assessment and, depending on the patient's score, they are given a certain dose of benzodiazepine.
• The patient should not drive whilst undergoing benzodiazepine detoxification.

Thiamine:

• Thiamine deficiency is common in people who are alcohol-dependent due to their poor diet, the presence of gastritis which can affect its absorption and also the fact that it is a coenzyme in alcohol metabolism.⁶
• Deficiency can cause Wernicke's encephalopathy, which if left untreated can lead to Korsakoff's syndrome.⁶
• Oral thiamine is poorly absorbed in dependent drinkers. For this reason, all those undergoing detoxification in the community should be considered for parenteral high potency B complex vitamins (Pabrinex®) as prophylactic treatment. However, because of the risk of anaphylaxis, resuscitation facilities need to be available at the time of administration. The risk of anaphylaxis is lower if the drug is given intramuscularly.⁷
• As prophylactic treatment, one pair of ampoules of Pabrinex® should be given intramuscularly or intravenously once a day for three to five days. A pair of ampoules contains 250 mg of thiamine.⁷
• If the patient is healthy and well nourished, and alcohol dependence is uncomplicated, then an alternative is oral thiamine at a minimum dose of 300 mg per day during detoxification.⁷
• Ongoing prescription of lower doses of thiamine are suggested if there is concern about chronic deficiency after this. CKS recommends that 50 mg daily be taken.⁶

This is a medical emergency. A hyperadrenergic state is present.

Clinical features

• Delirium tremens usually begins 24-72 hours after alcohol consumption has been reduced or stopped.¹¹
• The symptoms/signs differ from usual withdrawal symptoms in that there are signs of altered mental status. These can include:¹¹
  • Hallucinations (auditory, visual, or olfactory)
  • Confusion
  • Delusions
  • Severe agitation
• Seizures can also occur.
• Examination may reveal signs of chronic alcohol abuse/stigmata of chronic liver disease. There may also be:¹¹
  • Tachycardia
  • Hyperthermia and excessive sweating
  • Hypertension
  • Tachypnea
  • Tremor
  • Mydriasis
  • Ataxia
  • Altered mental status
  • Cardiovascular collapse

Risk factors^5,11

• Previous history of delirium tremens
• Previous history of alcohol withdrawal seizures
• Coexisting infection or medical problems including pancreatitis or hepatitis
• Recent higher than normal levels of alcohol intake
• Older age
• Abnormal liver function
• More severe withdrawal symptoms on presentation

Investigations¹¹

This is a clinical diagnosis and there is often a known history of alcohol misuse/dependence.

• Blood tests can help to assess other medical problems. Dehydration and electrolyte disturbance may be present. Tests can include:
  • Full blood count
  • Liver function tests
  • Clotting
  • Arterial blood gases (to look for metabolic acidosis)
  • Glucose
  • Blood alcohol levels
  • Urea, electrolytes and creatinine
  • Amylase
  • Creatine phosphokinase (especially if patient was unconscious for a long time due to risk of rhabdomyolysis)
  • Blood cultures (if there are concerns about infection)
• Chest X-ray should be considered if there are signs of respiratory distress. Coexisting pneumonia is common. There is also the possibility of aspiration, especially if reduced consciousness or seizures have occurred.
• CT head may be needed if there are seizures or evidence of a recent head injury.
• ECG may show an arrhythmia.

Management

• This should be in a hospital setting. Intensive care may be needed for very unwell patients.
• It should first include assessment and management of Airway, Breathing and Circulation.
• Any hypoglycaemia should be treated.
• Sedation with benzodiazepines is suggested. Diazepam has a rapid onset of action.¹¹
• Addition of barbiturates may also be necessary in those refractory to benzodiazepine treatment and may reduce the need for mechanical ventilation in very unwell patients in the intensive care unit.^11,12
• Patients with delirium tremens may also have Wernicke’s encephalopathy and should be treated for both conditions:⁷
  • At least two pairs of ampoules of Pabrinex® (500 mg thiamine) should be given intravenously three times daily for three days
  • If the patient does not respond, treatment should be discontinued
  • If signs or symptoms respond to treatment, continue with two ampoules of Pabrinex® once daily for five days, or for as long as improvement continues
• Magnesium may also protect against seizures and arrhythmias.¹¹

Prognosis

• The mortality rate can be up to 35% if untreated but is less than 5% with early recognition and treatment.¹¹

• Close follow-up is needed.
• Counselling, self-help and groups including Alcoholics Anonymous may be helpful.
• In those discharged from secondary care, involvement of the patient's GP (with their permission) should be encouraged.
• Drugs can be used in abstinence to help prevention of relapse. These are discussed in the separate article Alcoholism and Alcohol Abuse - Management.
• Any co-existing medical and psychological problems should also be addressed.

• If problem drinking is identified early, it may mean that complications, including severe alcohol withdrawal and delirium tremens, are avoided.
• Patients admitted to hospital should also be screened for alcohol dependence.