Alcohol withdrawal syndrome in hospitalized patients: a practical review

Alcohol withdrawal syndrome (AWS) develops in patients with alcohol use disorder (AUD) and physical dependence after abrupt cessation or substantial reduction of sustained heavy alcohol use. It is common and potentially life-threatening in general medical practice. Characteristic features include tremor, autonomic activation, anxiety, insomnia, perceptual disturbances, seizures, and delirium tremens. This practical review aims to guide internists in early recognition, risk stratification, monitoring, pharmacological treatment, and transition to longitudinal AUD care. Most hospitalized patients can be managed effectively when physicians identify early high-risk features, select an appropriate level of monitoring, and use approved first-line therapy. Supportive care, including thiamine, hydration, electrolyte correction, and reassessment for differential diagnoses, is essential. Benzodiazepines remain the standard of care for moderate to severe withdrawal, but decisions should reflect withdrawal history, current severity, comorbidity, and symptom-scale limitations in medically complex patients. Benzodiazepine-based protocols include symptom-triggered therapy, fixed-dose therapy, and front loading; choosing among them should depend on the patient's risk profile, ability to participate in symptom scoring, and monitoring environment. Phenobarbital is increasingly used within standardized, closely monitored hospital protocols with appropriate expertise, whereas clomethiazole and sodium oxybate remain region-specific alternatives in some European countries. This review also emphasizes delirium tremens and refractory withdrawal, including when higher-acuity care and adjunctive sedatives should be considered. Hospitalization should be used to initiate treatment for AUD and reduce recurrent withdrawal, readmission, and mortality.