Management of Alcohol Withdrawal Syndrome in Patients with Alcoholic Liver Disease

Abstract

Alcohol withdrawal syndrome (AWS) is a common condition that is seen in treatment-seeking patients with Alcohol use disorder (AUD) and alcoholic liver disease (ALD). AWS, which typically starts within 4-6 h of the last alcohol use, can range from mild symptoms such as insomnia, tremors, and autonomic hyperactivity to more severe symptoms such as seizures and delirium tremens. Clinical Institute Withdrawal Assessment Scale-Alcohol Revised (CIWA-Ar) is the most commonly used scale to assess AWS in clinical practice. The presence of moderate withdrawal as indicated by a score of more than 8 is an indication for pharmacotherapy. Lorazepam and oxazepam are preferred agents for the management of AWS in the setting of ALD. In severe ALD, benzodiazepines should be used cautiously with monitoring due to the risk of excessive sedation or precipitating hepatic encephalopathy.

Keywords: ALD, alcoholic liver disease; AMPA, α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid; AUD, alcohol use disorder; AUDIT – C, Alcohol Use Disorder Identification Test – Consumption; AUDIT, Alcohol Use Disorder Identification Test; AWS, alcohol withdrawal syndrome; CIWA – Ar, Clinical Institute Withdrawal Assessment for Alcohol Revised; CNS, central nervous system; EtG, ethyl glucuronide; EtS, ethyl sulphate; GABA, gamma-aminobutyric acid; GGT, gamma glutamyl transferase; HE, hepatic encephalopathy; MCV, mean corpuscular volume; NMDA, N-methyl-d-aspartate; alcohol; alcoholic liver disease; assessment; treatment; withdrawal.