The alcohol withdrawal syndrome

Department of Neurology and Clinical Neurosciences, Beaumont Hospital, Dublin, and Royal College of Surgeons in Ireland, Dublin, Ireland.
Journal of neurology, neurosurgery, and psychiatry (Impact Factor: 6.81). 09/2008; 79(8):854-62. DOI: 10.1136/jnnp.2007.128322
Source: PubMed


The alcohol withdrawal syndrome (AWS) is a common management problem in hospital practice for neurologists, psychiatrists and general physicians alike. Although some patients have mild symptoms and may even be managed in the outpatient setting, others have more severe symptoms or a history of adverse outcomes that requires close inpatient supervision and benzodiazepine therapy. Many patients with AWS have multiple management issues (withdrawal symptoms, delirium tremens, the Wernicke-Korsakoff syndrome, seizures, depression, polysubstance abuse, electrolyte disturbances and liver disease), which requires a coordinated, multidisciplinary approach. Although AWS may be complex, careful evaluation and available treatments should ensure safe detoxification for most patients.

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Available from: Andrew Mckeon, Jul 15, 2014
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    • "In about 80% of cases, the symptoms of uncomplicated alcohol withdrawal do not require aggressive medical intervention and usually disappear within 2–7 days of the last drink (Victor and Adams, 1953). As a result, unnecessary prophylaxis or treatment with benzodiazepine and other agents facilitating Gamma- Aminobutyric Acid (GABA) transmission in patients feared to be at risk of AWS but only experiencing uncomplicated AWS may lead to a number of unintended consequences including excessive sedation, falls, respiratory depression and medication-induced delirium (Johnson, 1961; Maldonado, 2008; 2010; Maldonado et al., 2010). Due to lack of any similar previously existing tools, we developed the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) (Maldonado et al., 2014). "
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    ABSTRACT: The prevalence of alcohol use disorders (AUDs) among hospitalized medically ill patients exceeds 40%. Most AUD patients experience uncomplicated alcohol withdrawal syndrome (AWS), requiring only supportive medical intervention, while complicated AWS occurs in up to 20% of cases (i.e. seizures, delirium tremens). We aimed to prospectively test and validate the Prediction of Alcohol Withdrawal Severity Scale (PAWSS), a new tool to identify patients at risk for developing complicated AWS, in medically ill hospitalized patients. We prospectively considered all subjects hospitalized to selected general medicine and surgery units over a 12-month period. Participants were assessed independently and blindly on a daily basis with PAWSS, Clinical Institute Withdrawal Assessment-Alcohol, Revised (CIWA-Ar) and clinical monitoring throughout their admission to determine the presence and severity of AWS. Four hundred and three patients were enrolled in the study. Patients were grouped by PAWSS score: Group A (PAWSS < 4; considered at low risk for complicated AWS); Group B (PAWSS ≥ 4; considered at high risk for complicated AWS). The results of this study suggest that, using a PAWSS cutoff of 4, the tool's sensitivity for identifying complicated AWS is 93.1% (95%CI[77.2, 99.2%]), specificity is 99.5% (95%CI[98.1, 99.9%]), positive predictive value is 93.1% and negative predictive value is 99.5%; and has excellent inter-rater reliability with Lin's concordance coefficient of 0.963 (95% CI [0.936, 0.979]). PAWSS has excellent psychometric characteristics and predictive value among medically ill hospitalized patients, helping clinicians identify those at risk for complicated AWS and allowing for prevention and timely treatment of complicated AWS. © The Author 2015. Medical Council on Alcohol and Oxford University Press. All rights reserved.
    Alcohol and Alcoholism 05/2015; 50(5). DOI:10.1093/alcalc/agv043 · 2.89 Impact Factor
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    • "These manifestations of alcohol withdrawal have been especially related to decreases in dopamine and GABA (Gilpin & Koob, 2008; Sanna et al., 2003), along with increases in glutamate activity (Gass & Olive, 2008; Kalivas, 2008). The syndrome frequently includes anxiety, tremors, agitation, delirium, and eventually seizures (McKeon et al., 2008). In rodents, it may be manifested as anxiety, decrease of exploratory behavior, and hypoactivity (Fukushiro et al., 2012; Kliethermes, 2005; Slawecki & Roth, 2004). "
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    ABSTRACT: N-acetylcysteine (NAC), a glutamate-modulating agent with antioxidant and anti-inflammatory properties, has been considered as a potential anti-addictive drug. Beneficial effects were reported for cocaine, cannabis, and tobacco addicts, but the effect of NAC in alcoholics or in alcohol animal models is unknown. The aggravation of alcohol withdrawal symptoms, such as anxiety, has been associated with increased levels of serum corticosterone and leptin. Thus, the aim of this study was to assess the effects of NAC on anxiety, as well as corticosterone and leptin serum levels, after cessation of chronic alcohol treatment in rats. Male Wistar rats were treated with 2 g/kg ethanol, twice daily, by gavage for 30 days; control animals received an appropriate dose of glucose to balance caloric intake. Rats were treated for 4 days with NAC (60 and 90 mg/kg, intra-peritoneally [i.p.]) or saline after alcohol cessation. Twenty-four hours after the last treatment, rats were exposed to a 5-min session in the open-field test (OF). Corticosterone and leptin serum levels were determined by ELISA in samples collected within 30 min after the OF. Results showed that rats were hypoactive (decreased rearing, peripheral, and total crossings), and that corticosterone and leptin levels were increased 5 days after alcohol cessation. Four days of NAC prevented the behavioral and biochemical changes brought about by alcohol cessation. We suggest that, in addition to the anti-addictive properties reported for other drugs of abuse, NAC is potentially useful in the management of alcohol withdrawal. Copyright © 2015 Elsevier Inc. All rights reserved.
    Alcohol (Fayetteville, N.Y.) 02/2015; 49(3). DOI:10.1016/j.alcohol.2015.01.009 · 2.01 Impact Factor
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    • "Abrupt cessation of regular intake of ethanol in a dependent person causes a withdrawal syndrome (McKeon, Frye, & Delanty, 2008). Ethanol withdrawal syndrome generally begins 6e24 h after the last intake of ethanol, and the signs and symptoms include agitation, tremors, sweating, nausea, vomiting, seizures, hallucinations , insomnia, delirium, anxiety, tachycardia, and hypertension (McKeon et al., 2008). Some studies show that arterial blood pressure is elevated during ethanol withdrawal (Clark & Friedman, 1985; King, Errico, Parsons, & Lovallo, 1991). "
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    ABSTRACT: We analyzed the effects of ethanol withdrawal on the vascular and systemic renin-angiotensin system (RAS) and vascular oxidative stress. Male Wistar rats were treated with ethanol 3–9% (v/v) for a period of 21 days. Ethanol withdrawal was induced by abrupt discontinuation of the treatment. Experiments were performed 48 h after ethanol discontinuation. Rats from the ethanol withdrawal group showed decreased exploration of the open arms of the elevated-plus maze (EPM) and increased plasma corticosterone levels. Ethanol withdrawal significantly increased systolic blood pressure and plasma angiotensin II (ANG II) levels without an effect on plasma renin activity (PRA), angiotensin converting enzyme (ACE) activity, or plasma angiotensin I (ANG I) levels. No differences in vascular ANG I, ANG II levels, and ACE activity/expression and AT1 and AT2 receptor expression were detected among the experimental groups. Plasma osmolality, as well as plasma sodium, potassium, and glucose levels were not affected by ethanol withdrawal. Ethanol withdrawal induced systemic and vascular oxidative stress, as evidenced by increased plasma thiobarbituric acid-reacting substances (TBARS) levels and the vascular generation of superoxide anion. Ethanol withdrawal significantly decreased plasma and vascular nitrate/nitrite levels. Major new findings of the present study are that ethanol withdrawal induces vascular oxidative stress and reduces nitric oxide (NO) levels in the vasculature. Additionally, our study provides novel evidence that ethanol withdrawal does not affect the vascular ANG II generating system while stimulating systemic RAS. These responses could predispose individuals to the development of cardiovascular diseases.
    Alcohol 12/2014; 49(1). DOI:10.1016/j.alcohol.2014.12.001 · 2.01 Impact Factor
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