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Abstract
- When people who are physically
dependent on alcohol stop drinking,
they experience an alcohol withdrawal
syndrome. The symptoms generally
resolve spontaneously within a week,
but more severe forms may be associated
with generalised seizures, hallucinations
and delirium tremens, which
can be fatal.
- We carried out a literature review
in order to obtain answers to the following
questions: how to predict or
rapidly diagnose a severe alcohol withdrawal
syndrome; how to prevent and
treat this syndrome; how to manage
severe forms; and how to deal with the
risk of vitamin B1 deficiency.
- The main risk factors for severe
withdrawal syndrome are: chronic
heavy drinking; a history of generalised
seizures; and a history of delirium
tremens.
- Anxiety, agitation, tremor, excessive
sweating, altered consciousness and hallucinations
are signs of a severe withdrawal
syndrome.
- Individual support and effective
communication seem to reduce the
risk of severe withdrawal syndrome.
- Oral benzodiazepines are the best-assessed
drugs for preventing a severe
alcohol withdrawal syndrome, particularly
the risk of seizures. When given
for a maximum of 7 days, the adverse
effects are usually mild.
- Clinical trials of other antiepileptics
suggest they are less effective than benzodiazepines,
and their addition to benzodiazepine
therapy offers no tangible
advantage.
- Betablockers increase the risk of hallucinations,
and clonidine increases the
risk of nightmares, and the efficacy of
these two drugs is not well documented.
Neuroleptics increase the risk
of seizures.There are no convincing
data to support the use of magnesium
sulphate or meprobamate (the latter
carries a risk of serious adverse effects).
Acamprosate, naltrexone and disulfiram
are not beneficial in alcohol withdrawal.
- Gradual withdrawal, i.e. ingestion of
decreasing amounts of alcohol, has not
been compared with other methods
but is generally not recommended.
- There are no specific recommendations
on hydration. Note that excessive
water-sodium intake carries a risk
of pulmonary oedema in patients with
heart disease.
- As vitamin B1 deficiency is frequent
and can lead to serious complications
in alcohol-dependent patients, oral
vitamin B1 supplementation is widely
recommended, despite the absence of
comparative trials. High doses must be
used to compensate for poor absorption.
Intravenous administration is best
if patients have very poor nutritional
status or severe complications such as
Gayet-Wernicke encephalopathy (a
medical emergency), even though rare
anaphylactic reactions have been
reported after vitamin B1 injection.
- Planned alcohol withdrawal in specialised
hospital units has been extensively
studied. Outpatient withdrawal
may be more appropriate for patients
who are at low risk of developing
severe withdrawal syndrome.
- A large proportion of alcohol-dependent
patients were excluded from trials
of withdrawal strategies. These include elderly patients, patients with
serious psychiatric or somatic disorders,
and patients who are also dependent
on other substances.
- An oral benzodiazepine is the best-assessed
treatment for a single episode
of generalised seizures or hallucinations
during alcohol withdrawal.
- In randomised comparative trials benzodiazepines
were more effective than
neuroleptics in preventing delirium-related
mortality. Currently, with appropriate
fluid-electrolyte support, continuous
monitoring of vital signs, and respiratory
support if necessary, the mortality
rate for delirium tremens is under 3%.
