it's an review article based on the clinical symptoms that arise after the alcohol withdrawal that can get worse in just 2 days after the withdraw of alcohol this review includes the pathophysiology and management of AWS. Management includes both the allopathic and ayurvedic Management and thus keeping in mind that the disorder can go to chronic in just 2 days treatment should be started from day 1st and giving ayurvedic formulations can be a better choice over allopathic because these can be administered for a very long time compared to allopathic and also works on the root cause of disorder clear out toxicity and person starts to recover soon. Only limitation is can not be given in chronic state.

1. Unveiling Alcohol
Withdrawal
Syndrome: Exploring
Its Hidden Depths
Yash Garg

2. Index
Introduction
3
Conclusion
and
Reference
20
Diagnostic
criteria
8
Complications
17
Management
strategies
14
Alcohol effect
on brain
10
Prevalence
4
Symptoms
of AWS
6

3. Introduction
Alcohol, initially a matter of choice, often evolves into addiction, with cases of
dependency increasing annually. According to statistics, alcohol consumption rose
by 7.33% in 2023.1,2 Alcohol withdrawal syndrome (AWS) is a serious consequence of
this dependency, arising from abrupt or gradual reduction of alcohol intake when
individuals recognize its harmful effects and decide to quit. Symptoms of AWS
emerge swiftly after alcohol reduction, escalating within 2-3 days to include anxiety,
headaches, insomnia, and profuse sweating. Within 12-48 hours, symptoms worsen,
potentially leading to hallucinations and seizures. Delirium tremens, occurring in
approximately 5% of AWS cases, manifests with rapid heartbeat, elevated blood
pressure, fever, and excessive sweating within 24 hours. Notably, AWS typically only
happens to heavy drinkers. Treatment typically involves benzodiazepines and
anticonvulsants. This review aims to explore AWS pathophysiology, treatment
modalities, management strategies, and potential complications comprehensively.3

4. prevalence
Annual Consumptions

5. Alcohol consumption and disorder prevalence
0
1
2
3
4
5
6
2016-2018 2010 2003-2005
alcohol consumption per capita in ltrs 0
5
10
15
20
25
30
35
40
45
spirits beer RTDs wine
% consumption
India's alcoholic beverage market is
projected to grow annually by 7.33%
from 2023 to 2028. The country's
alcohol market ranks as the third
largest globally, following China and
Russia, with an estimated value of $35
billion. The largest segment within this
market is spirits. Additionally,
approximately 27% of individuals
between the ages of 18 and 64 years
meet the diagnostic criteria for alcohol
dependence. Among alcohol-
dependent patients, about 50%
experience clinically relevant
withdrawal symptoms, with prevalence
rates ranging from 13% to 71%. 3

6. Symptoms of AWS
5

7. Quitting alcohol isn’t a
big achievement, but
how you did it; is.
Yash Garg

8. Diagnostic criteria

9. 4

10. Alcohol
effect on
brain

12. Metabolism of alcohol
1.Alcohol Dehydrogenase (ADH): The first step in
alcohol metabolism involves the enzyme alcohol
dehydrogenase converting ethanol (the type of
alcohol found in beverages) into acetaldehyde. This
reaction releases hydrogen ions and electrons.
2.Acetaldehyde Dehydrogenase (ALDH):
Acetaldehyde, the product of the first step, is further
metabolized by the enzyme acetaldehyde
dehydrogenase into acetate. This step also involves
the release of hydrogen ions and electrons.
3.Acetate Metabolism: Acetate, the end product of
alcohol metabolism, is further metabolized into
carbon dioxide and water, which are then eliminated
from the body through respiration and urine. 6,7

13. Mechanism of action of AWS
In Alcohol Withdrawal Syndrome (AWS), hyperactivity arises due to an
imbalance in the number of GABA(A) receptors. The reduction in receptor
numbers disrupts the inhibitory mechanism, leading to a sudden increase in
excitatory activity. Concurrently, there's an upregulation of NMDA glutamate
receptors to compensate for this imbalance, but when alcohol intake is
reduced, it triggers hyperactivity. Similarly, in Alcohol-Induced Substance
Use Disorders (SUDs), opioid receptors undergo a similar mechanism as
glutamate receptors, resulting in a sudden depression of neurotransmitters.
This imbalance can manifest as anxiety and confusion.

14. Management strategies
AWS can be managed using two distinct approaches: one
from allopathic medicine and the other from Ayurveda.
Allopathic
• Medication management
• Supportive care
• Psychosocial support
Ayurvedic
• Detoxification (panchakarma)
• Herbal remedies
• Diet and lifestyle
modifications
• Ayurvedic medications

15. Allopathic
1. Medication Management:
1. Benzodiazepines: These are commonly used to manage symptoms of alcohol withdrawal, such as anxiety, agitation, and
seizures. Examples include diazepam, lorazepam, and chlordiazepoxide.
2. Anticonvulsants: Medications like carbamazepine or valproic acid may be used to prevent or treat alcohol withdrawal
seizures.
3. Other medications: Depending on the severity of symptoms and individual patient needs, other medications such as beta-
blockers (for managing tremors and heart rate) or antipsychotics (for managing hallucinations) may be prescribed.
2. Supportive Care:
1. Intravenous fluids and electrolyte replacement: This helps to address dehydration and electrolyte imbalances that may
occur during withdrawal.
2. Nutritional support: Malnutrition is common in individuals with alcohol use disorder, so ensuring adequate nutrition is
important.
3. Monitoring: Close monitoring of vital signs, symptoms, and any potential complications is crucial, especially for severe
cases.
3. Psychosocial Support:
1. Counseling: Cognitive-behavioral therapy (CBT), individual or group therapy, and support groups like Alcoholics
Anonymous (AA) can be beneficial in addressing underlying issues and providing ongoing support for recovery 9

16. Ayurvedic
1.Detoxification (Panchakarma):
1. Ayurvedic therapies like Virechana (therapeutic purgation) and Basti (medicated enema) may be used to
eliminate toxins from the body and restore balance. Eg. Kutki aka kali jiri (kutkin) eliminates in the form of
feaces.
2.Herbal Remedies:
1. Ayurvedic herbs like Ashwagandha, Brahmi, and Shankhpushpi may be used to help calm the nervous
system, reduce anxiety, and support overall well-being during the withdrawal process.
3.Diet and Lifestyle Modifications:
1. Dietary recommendations: Ayurvedic practitioners may suggest dietary changes and specific foods or herbs
to support detoxification and balance the body. Eg. Plum and imli good sources of vit. C and helps in liver
clearance.
2. Lifestyle advice: Recommendations may include stress management techniques, daily routines (dinacharya),
and practices like yoga and meditation to promote overall health and well-being.
4.Ayurvedic Medications (Herbal Formulations):
1. Ayurvedic formulations containing herbs like Saraswatarishta, Dashmoolarishta, or Brahmi Ghrita may be
prescribed to support the nervous system and promote relaxation 10

17. Complications
or risk factors

18. Complications or risk factors
1. Delirium tremens: A severe form of alcohol withdrawal characterized by confusion, hallucinations, agitation,
and autonomic instability.
2. Seizures: Abrupt changes in brain function due to excessive electrical activity, which may occur during alcohol
withdrawal.
3. Cardiovascular complications: These can include rapid heart rate, high blood pressure, and arrhythmias.
4. Respiratory depression: Reduced breathing rate and depth, leading to low oxygen levels in the blood.
5. Metabolic abnormalities: Imbalances in electrolytes such as potassium and magnesium, which can affect
various organ systems.
6. Psychiatric complications: Mood disturbances, anxiety, depression, and suicidal ideation may occur during
alcohol withdrawal.
7. Gastrointestinal issues: Nausea, vomiting, and gastrointestinal bleeding can occur, particularly in severe cases of
AWS.
8. Infections: Pneumonia and other infections may develop due to weakened immune function and compromised
respiratory status.
9. Injury: Patients experiencing severe symptoms of AWS, such as delirium tremens, may be at risk of accidental
injury due to confusion and disorientation.

19. Conclusion
In the comprehensive exploration of AWS, the outcomes
suggest that Ayurvedic formulations for calming the central
nervous system (CNS) emerge as a promising option over
medications recommended in allopathic medicine, such as
benzodiazepines. Ayurvedic formulations offer the
advantage of being potentially safer for long-term use
without addictive side effects. However, their limitation lies
in addressing acute symptoms rather than chronic ones,
where allopathic medications may be necessary due to their
rapid onset of action. Thus, while both approaches
contribute valuable insights and interventions, a holistic
treatment strategy that integrates the strengths of both
allopathic and Ayurvedic modalities may offer the most
effective approach to managing AWS.

20. Reference
1. Saitz, R. (1998). Introduction to Alcohol Withdrawal. Alcohol Health and Research World, 22(1), 5-12.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6761824/
2. https://www.webmd.com/mental-health/addiction/alcohol-withdrawal-symptoms-treatments
3. https://www.statista.com/outlook/cmo/alcoholic-drinks/india
4. Puz, C. A., & Stokes, S. J. (2005). Alcohol Withdrawal Syndrome: Assessment and Treatment with the Use of the Clinical
Institute Withdrawal Assessment for Alcohol-Revised. Critical Care Nursing Clinics of North America, 17(3), 297-304.
https://doi.org/10.1016/j.ccell.2005.04.001
5. Johnson, Santhi L. M.Sc (N)*; Theerthagiri, Velvizhi B.Sc (N)**; Sathiyaseelan, Manoranjitham M.Sc (N)., Ph.D (N)***.
Alcohol Withdrawal: A Case Report. Indian Journal of Continuing Nursing Education 16(1):p 17-24, Jan–Jun 2015.
6. Zakhari, S. (2006). Overview: How Is Alcohol Metabolized by the Body? Alcohol Research & Health, 29(4), 245-254.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6527027/
7. Muehlberger CW. THE PHYSIOLOGICAL ACTION OF ALCOHOL. JAMA. 1958;167(15):1842–1845.
doi:10.1001/jama.1958.72990320013008
8. BECKER, H. C., & MULHOLLAND, P. J. (2014). NEUROCHEMICAL MECHANISMS OF ALCOHOL WITHDRAWAL.
Handbook of Clinical Neurology, 125, 133. https://doi.org/10.1016/B978-0-444-62619-6.00009-4
9. Mirijello, A., D’Angelo, C., Ferrulli, A. et al. Identification and Management of Alcohol Withdrawal Syndrome. Drugs 75,
353–365 (2015). https://doi.org/10.1007/s40265-015-0358-1
10. Sharma, A., Yadav, S., & Vishnoi, R. (2022, March 20). Ayurvedic Management of Alcohol Withdrawal
Syndrome - Case Series. International Journal of AYUSH Case Reports, 6(1), 135-146. Retrieved from
https://ijacare.in/index.php/ijacare/article/view/290

21. Yash Garg
Pharmacist
yashgarg90687@gmail.com
Doon valley institute of
pharmacy and medicine,
karnal