Alcohol withdrawal syndrome (AWS) refers to the excitatory state that develops after a sudden cessation of or reduction in alcohol consumption following a period of prolonged heavy drinking. It is characterized by a variety of clinical features, including tremor, insomnia, anxiety, and autonomic instability. AWS is considered to be complicated if patients present with or develop alcohol withdrawal seizures, alcohol withdrawal delirium, or alcohol-induced psychotic disorder. AWS is a clinical diagnosis of exclusion based on characteristic symptoms in at-risk patients with recent reduction or cessation of alcohol consumption. Patients with AWS may also present with concomitant diseases that require treatment (e.g., alcoholic hepatitis, complicated cirrhosis) or develop AWS during periods of hospitalization for unrelated comorbidities. The management of uncomplicated and complicated AWS includes hydration, nutritional support, and thiamine to prevent or treat concomitant Wernicke encephalopathy, as well as pharmacological management with benzodiazepines and/or anticonvulsants to reduce symptoms and prevent disease progression and death. Most patients require hospital admission for monitoring and treatment.
AWS is typically described as the progression through the stages of alcohol withdrawal, from minor to severe withdrawal with or without complicated disease. Not all patients progress through all of the stages of AWS, especially elderly patients and/or patients taking hypnotic or anxiolytic medications.
Alcohol withdrawal syndrome (uncomplicated) 
- Onset: : usually 6–24 hours after cessation of or reduction in alcohol consumption 
- Clinical features: can appear on a spectrum of severity from mild to severe (see “Classification”)
Alcohol withdrawal seizures 
- Onset: : usually 8–48 hours after cessation of or reduction in alcohol consumption 
- Clinical features
Withdrawal seizures may occur without prior significant features of AWS and may be the presenting symptom in some patients.
Alcohol-induced psychotic disorder (alcoholic hallucinosis) 
- Onset: : usually 12–24 hours after cessation of or reduction in alcohol consumption 
- Clinical features
- Duration: 24–48 hours after onset 
Alcohol withdrawal delirium (delirium tremens) 
- Definition: : persistent alteration of consciousness and sympathetic hyperactivity due to alcohol withdrawal
- Onset: usually 72–96 hours after cessation of or reduction in alcohol consumption
Symptoms of altered mental status
- Impaired consciousness and disorientation
- Visual and tactile hallucinations (usually small moving objects, e.g., mice, crawling insects), oneirism (a condition characterized by visual hallucinations, typically experienced during a waking state, that are dreamlike and rich in detail)
- Increased suggestibility
- Worsening symptoms of autonomic instability
- Worsening symptoms of neurological impairment
- Symptoms of altered mental status
- Duration: : usually 2–3 days; may be lethal
Classification by syndrome 
Complicated alcohol withdrawal refers to AWS with any of the following:
- Resistant alcohol withdrawal: severe symptoms of AWS or the presence of complications despite the use of high benzodiazepine doses 
Classification by severity 
|Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) |
|Minimal possible score (no symptoms)||Maximal possible score (severe symptoms)|
|Nausea or vomiting|| |
|Persistent nausea or vomiting (7)|
|Tremors||Severe tremors (7)|
|Anxiety||Acute panic (7)|
|Agitation||Severe agitation (7)|
|Tactile disturbances||Continuous hallucinations (7)|
|Auditory disturbances||Continuous hallucinations (7)|
|Visual disturbances||Continuous hallucinations (7)|
|Paroxysmal sweats||Drenching sweat (7)|
|Headache||Extremely severe (7)|
|Orientation||Oriented and can do serial additions (0)||Disoriented for person and/or place (4)|
Interpretation (total combined score) 
- Clinical diagnosis: Suspect AWS in patients with characteristic clinical features and a history of alcohol use disorder who have recently ceased or reduced their alcohol consumption (use the “”).
- Complicated AWS should be considered if any of the following are present:
- Order routine diagnostic studies and blood alcohol concentration.
- Consider additional investigations based on suspected comorbidities and .
- Screen for and .
Patients with AWS often have other disorders that also require urgent identification and treatment (e.g., , , , , ).
Individuals with chronic alcohol use who are hospitalized often develop withdrawal symptoms 48–72 hours after admission because they do not have access to alcohol in the hospital. Consider screening admitted patients for alcohol use disorder using a validated tool (e.g., or ).
Clinical diagnostic criteria 
|DSM-5 diagnostic criteria for alcohol withdrawal syndrome|
|Fundamental criteria|| |
|Presence of ≥ 2 symptoms|
|Symptom characteristics|| |
Additional investigations 
- Routine laboratory studies: Laboratory alterations detected in patients with AWS are often attributable to chronic alcohol use disorder.
- Blood alcohol concentration (BAC): Symptoms that occur while BAC is still detectable or high carry a poor prognosis for progression to severe AWS.
- Other tests to consider 
Laboratory findings in AWS are usually attributable to chronic alcohol use disorder and tend to be mild. Marked alterations should prompt suspicion for comorbid conditions.
- Anticipate and prevent alcohol withdrawal in at-risk patients hospitalized for other reasons.
- Classify AWS severity using a validated scale, e.g., CIWA-Ar.
- Perform complicated AWS): e.g., identify and/or calculate score. (to predict severe or
- Adjust pharmacotherapy and disposition according to individual symptom severity and risk of progression (see “. ”)
- Consider using severity scale (e.g., CIWA-Ar) to monitor response to treatment.
- Identify and manage any complications without delay (see “. ”)
- Alcohol withdrawal seizures: Immediately administer IV benzodiazepines.
- Alcohol-induced psychotic disorder: Consider ; low-dose antipsychotics (e.g., haloperidol; , risperidone) in combination with benzodiazepines (not as monotherapy).
- Alcohol withdrawal delirium: Consider referral to critical care unit for high-dose IV benzodiazepines and monitoring.
- Provide supportive care to all patients during the withdrawal episode (e.g., nutritional and metabolic support).
- Consider brief interventional during hospitalization.
- Provide referral for long-term therapy if the patient is interested.
See “Pharmacological treatment regimens for AWS” for detailed recommendations and dosages.
- First-line: benzodiazepines
- Second-line: Anticonvulsants can be used in AWS if there are or as adjunctive treatment in resistant AWS.
Lorazepam, Oxazepam, and Temazepam are preferred for individuals who drink a LOT (have alcoholic liver disease), because hepatic dysfunction does not have a strong effect on their metabolism. Lorazepam, Oxazepam, and Temazepam are preferred for individuals who drink a LOT (have alcoholic liver disease), because hepatic dysfunction does not have a strong effect on their metabolism. All benzodiazepines are metabolized by the liver, but these three undergo biotransformation through glucuronidation, not CYP 450 activation, and are less affected by liver disease. 
Supportive care 
- Hydration: : Provide as needed and start .
Metabolic support: Assess nutritional status and need for vitamin and mineral replacement.
- Consider multivitamins.
- Provide folate for critically ill patients. 
- : e.g., for hypokalemia, hyponatremia, or hypomagnesemia
- : oral glucose or IV (see also “Alcoholic ketoacidosis”)
- Thiamine supplementation
- Fixed-dose combined vitamin and mineral replacement (i.e., the “banana bag” approach): no longer recommended as part of routine management; 
- Comorbidites: Treat any identified coexisting illnesses, e.g., toxic co-ingestions, GI bleeding, sepsis, alcoholic hepatitis, pancreatitis, injuries, depression, suicidality
Do not delay glucose administration when indicated; evidence suggests that it is safe to administer glucose without prior thiamine supplementation. 
Risk and severity-based management
Risk assessment for alcohol withdrawal
Multifactorial risk assessment is recommended for patients on an individual basis.
Red flags for alcohol withdrawal 
- Patient characteristics
Related to the current withdrawal episode
- Severe AWS: e.g. significant autonomic hyperactivity
- Complicated AWS: e.g., seizures during the current withdrawal episode
- Presence of AWS symptoms with detectable BAC
- Additional acute illness
- Significant abnormal laboratory results (see “Diagnostics”)
- Simultaneous withdrawal from other substances or significant use of or dependence on other drugs
Related to previous withdrawal episodes
- Multiple prior AWS episodes
- History of complicated AWS
Validated risk scores 
Different risk scores are used in clinical practice due to varying advantages and limitations. 
CIWA-Ar: higher value as a severity score than a risk score.
- Clinical applications
- Establishing baseline severity
- Monitoring of progression
- Evaluating response to treatment
- Subjectivity in assessment parameters
- Difficult to apply to uncommunicative or uncooperative patients
- Less predictive of the risk of severe AWS, complicated AWS, or future withdrawal.
- Clinical applications
- PAWSS score: greater predictive value to identify hospitalized patients at risk of complicated AWS 
|Prediction of alcohol withdrawal severity scale (PAWSS) |
|Features||Score if present|
|Historical||Within last 30 days||Intoxication or drunkenness||1|
|Within last 90 days||Co-ingestion of sedative-hypnotics||1|
|Co-ingestion of other substances of abuse||1|
|Any prior||Alcohol withdrawal syndrome||1|
|Alcohol withdrawal seizures||1|
|Alcohol withdrawal delirium||1|
|Rehabilitation therapy for alcohol use disorder||1|
|Clinical||Autonomic hyperactivity (e.g., agitation, heart rate > 120/min, tremor, diaphoresis, nausea)||1|
|Diagnostic||BAC > 200 mg/dL at presentation||1|
Management algorithm 
Most patients require inpatient management.
|Management algorithm for alcohol withdrawal syndrome |
E.g., PAWSS ≥ 4, and/or
|Suggested initial pharmacotherapy||Monitoring and disposition|
|Mild (CIWA-Ar < 10)||Absent|| |
|Moderate (CIWA-Ar 10–18)||Absent|| || |
Severe (CIWA-Ar ≥ 19)
Monitor for signs of oversedation in all patients with AWS receiving pharmacological therapy.
Outpatient management of patients with moderate or severe alcohol withdrawal without red flags for AWS should only be considered if specialized centers and facilities for ambulatory monitoring are available, or if management can be provided by an experienced clinician. 
Management of complicated AWS 
Complications can occur at any point during withdrawal (e.g., upon presentation) and often necessitate escalation of the level of care (e.g., specialist or critical care consultation and high-dose pharmacotherapy). Follow local protocols if available.
Alcohol withdrawal seizures: Rapid administration of parenteral fast-acting benzodiazepines: e.g., diazepam
- Continue monitoring every 1–2 hours for 6–24 hours.
- If there is no response to benzodiazepines, administer .
- Alcohol-induced psychotic disorder: consider combination therapy in consultation with a specialist
- Alcohol withdrawal delirium 
- After acute symptoms resolve, continue a pharmacological to prevent recurrences.
- Consider ICU admission and specialist consultation.
These patients often require large doses of benzodiazepines, increasing the risk of oversedation and respiratory depression. Ensure that resuscitative equipment is readily available (e.g., bag-mask ventilation, supplemental O2, advanced airway devices).
- Choose the most suitable pharmacological regimen based on the . 
- Discontinue benzodiazepines as soon as AWS is resolved to reduce the potential for dependence. 
|Pharmacological treatment regimens for AWS |
|Drug class||Indications and rationale||Sample agents and doses|
|Benzodiazepines||Single-dose regimen for AWS|
|Front-loading dose for AWS|
|Symptom-triggered regimen for AWS|
|Fixed-schedule regimen for AWS|
|Anticonvulsants for AWS||Alternative therapy for AWS|
|Adjunctive therapy for AWS|| |
Hepatic impairment can cause the accumulation of benzodiazepines and their active metabolites. Consider preferentially using lorazepam, oxazepam, or temazepam in patients with liver disease to reduce the risk of oversedation. 
As a rule of thumb, the following doses of benzodiazepines are considered roughly equivalent in patients with normal hepatic function: diazepam 5 mg, chlordiazepoxide 25 mg, lorazepam 1 mg, and oxazepam 15 mg. 
Acute management checklist
- Patient is unstable or complications are present: follow ABCDE approach.
- Start as soon as it is suspected.
- Consider critical care consult.
- Confirm the diagnosis clinically, applying the .
- Order routine diagnostic studies: e.g., CBC, BMP, serum magnesium, LFTs, INR, albumin, BAC
- Consider investigations for alternate diagnoses: e.g., septic workup, delirium workup, neuroimaging, toxicological screening.
- Identify comorbidities based on clinical suspicion, e.g., pancreatitis. , ,
- Screen for depression and suicidal ideation: e.g., PHQ-2, modified SAD PERSONS scale
- Perform a .
- Start benzodiazepines) based on the suggested or local protocols. (e.g.,
- Ensure supportive care, e.g., IV fluids, thiamine, treatment of hypoglycemia, and electrolyte repletion.
- Determine disposition and monitoring based on individual risk and severity.
- Mild AWS (CIWA-Ar < 10) and absent high-risk features: Consider outpatient management; at least daily monitoring for 5 days.
- All other patients: Usually require inpatient admission; frequent monitoring based on individual risk (e.g., clinical monitoring and CIWA-Ar every 1–4 hours for the first 24 hours)
- Complicated AWS, poorly controlled or very severe AWS (CIWA-Ar > 35), high benzodiazepine requirement, and/or respiratory complications: Consider ICU admission.