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Unveiling Alcohol
Withdrawal
Syndrome: Exploring
Its Hidden Depths
Yash Garg
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
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
prevalence
Annual Consumptions
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
Symptoms of AWS
5
Quitting alcohol isn’t a
big achievement, but
how you did it; is.
Yash Garg
Diagnostic criteria
4
Alcohol
effect on
brain
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
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.
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
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
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
Complications
or risk factors
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.
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.
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
Yash Garg
Pharmacist
yashgarg90687@gmail.com
Doon valley institute of
pharmacy and medicine,
karnal

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Unveiling Alcohol Withdrawal Syndrome: exploring it's hidden depths

  • 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
  • 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
  • 7. Quitting alcohol isn’t a big achievement, but how you did it; is. Yash Garg
  • 9. 4
  • 11.
  • 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
  • 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