Alcohol Withdrawal Syndrome
A little alcohol can be a bad thing. A little less may be even worse - Stuart P. Swadron MD
image by: Schick Shadel Hospital
Alcohol withdrawal is everywhere. We see over half a million patients in U.S. EDs for alcohol withdrawal every year. Despite these huge volumes of patients and the diagnosis of alcohol withdrawal seeming relatively straightforward, it’s actually missed more often than we’d like to admit, being confused with things like drug intoxication or sepsis. Or it’s not even on our radar when an older patient presents with delirium.
The differential diagnosis is enormous – and no blood test on the planet will help us diagnose alcohol withdrawal. In fact, the diagnosis is entirely a clinical one. What’s even more surprising is that even if we do nail the diagnosis, observational studies show…
The first line medication for treating patients with alcohol withdrawal is benzodiazepines. The drug of choice is diazepam because it has a long half-life of ~100 hours, and carries a decreased risk of developing serious withdrawal symptoms once the patient is discharged. Diazepam also has a faster onset of action than lorazepam. It is important to remember that diazepam should be avoided in patients with overt liver failure or a history of liver failure.
Even though more than half a million patients are seen in U.S. emergency departments for alcohol withdrawal each year, this seemingly straightforward diagnosis is missed more often than we may believe.1 Even when it is picked up, it is often mismanaged. Why?
There are numerous (perhaps innumerable) reasonable ways to treat alcohol withdrawal. Prior to the ~1970s, barbiturates were front-line agents. Following a push by pharma to market newly developed benzodiazepines, this shifted to benzodiazepines. This transition wasn't based upon any evidence that benzodiazepines deserved to be front-line agents, but rather perhaps the perception that benzodiazepines were newer and therefore must be better. Currently, the pendulum is swinging back to barbiturates. Those lacking a historical perspective will view benzodiazepines as conventional front-line therapy, but in the larger context of medical history the use of benzodiazepines for alcohol withdrawal may wind up having been a mistake.
common and can be fatal. manifests within 48 hours of stopping drinking.
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