Exploring alcohol withdrawal and therapeutic strategies in a tertiary teaching hospital in Nagapattinam

References

1. standardTotal (n) (%)Mean SD Sig Hemoglobin Mild Anemia (9 – 10.9 g/dl) 5(3.3%) 9.1250 1.99153 0.0001* Moderate Anemia (7 – 9 g/dl) 18(12%) 7.8167 1.17536 Severe Anemia (Less than 7g/dl) 1(1%) 6.5 - Hyponatremia Hypernatremia <135 mEq/l 19(12.6%) 132.5675 2.56854 0.0006** >145 mEq/l 7(4.6%) 148.5626 1.59785 Hypokalemia Hyperkalemia <3.5 mEq/l 17(11.3%) 3.2514 0.54845 0.1516*** >5.2 mEq/l 1(0.6%) 5.2 - SGOT SGPT >46 U/L 21(14%) 50.5646 18.65666 0.0001*** >57 U/L 18(12%) 63.4156 12.61418 P - value <0.05 is considered as significance **One-way ANOVA test *** student t- test
2. To analyze the biochemical abnormalities reported in patients specific to alcohol withdrawal admission Out of the 150 subjects studied, 5 (3.3%) patients were iden- tified with mild anemia, followed by 18 (12%) patients with moderate anemia and 1 (1%) patient with severe anemia. Out of the 150 subjects, 19 (12.6%) patients had hypona- tremia and 17 (11.3%) patients had hypokalemia. Among the 150 patients, the SGOT level is higher in 21 (14%) patients, and the SGPT level is higher in 18 (12%) patients. This is indicated in (Table 5).
3. Treatment patterns in patients with alcohol withdrawal syndrome During hospitalization, the most common approach to treating patients with alcohol withdrawal syndrome is with benzodiazepines and adjunctive treatment. Among the benzodiazepines, the most commonly prescribed drug is diazepam (68.6%), followed by lorazepam (18%). Thiamine (86.6%) and normal saline (66.6%) were the most commonly used adjuvant care for the patients. Thirunanamoorthy et al. / Indian Journal of Pharmacy and Pharmacology 2025;12(3):137–143 141 Antiepileptics were also prescribed for 48% of patients, with the most common one being phenytoin (34.6%). This data is presented in (Table 6). Table 6: Treatment approaches in patients with alcohol withdrawal syndrome Drugs No. of patients N=150 Total percentage Benzodiazepines Diazepam 103 68.6% Lorazepam 27 18% Clonazepam 20 13.3% Adjuvant care Thiamine 130 86.6% Normal saline 100 66.6% Vitamin K 10 6.6% Vitamin B12 30 20% Antiepileptics Valproic Acid 12 8% Phenytoin 52 34.6% Levetiracetam 8 5.3% Antipsychotics Haloperidol 2 1.3%
4.  Discussion The present study aimed to assess the severity of Alcohol Withdrawal Syndrome (AWS), identify associated clinical and biochemical factors, and evaluate treatment patterns using the CIWA-Ar scale. A key finding was that the majority (77.3%) of patients experienced moderate withdrawal symptoms, suggesting that a structured screening and treatment protocol is essential in general medicine wards (Table 2). The CIWA-Ar tool helped quantify severity and guided timely pharmacological interventions, reinforcing its role in clinical practice. Demographic data (Table 1) revealed that most patients were middle-aged (36–40 years), married, employed, and from nuclear families with limited education. This socioeconomic profile is indicative of a vulnerable group with high alcohol dependence and poor awareness of withdrawal risks. 10 The findings point to a need for targeted community education and intervention programs. 11 Symptom patterns (Table 3) showed that while nausea, tremors, and anxiety were commonly reported across all severity levels, symptoms like agitation and tactile disturbances were more specific to moderate and severe AWS. This observation is consistent with the findings of Ankur Sachdeva et al. 1 This distinction suggests that while common symptoms may trigger clinical suspicion, the presence of agitation or sensory disturbances may warrant more intensive monitoring. Clinical correlations (Table 4) indicated a significant positive correlation between time since last alcohol intake and symptom severity, while age and duration of alcohol use showed weak negative correlations. These findings emphasize that the timing of last alcohol use is a more reliable predictor of withdrawal intensity than patient age or chronicity of use. This highlights the importance of obtaining accurate history during the initial assessment. These results differ from the findings of Ankur Sachdeva et al. 1 Biochemical abnormalities (Table 5), such as hyponatremia (12.6%), hypokalemia (11.3%), and elevated SGOT/SGPT levels, were prevalent. 10 These findings reflect the metabolic disturbances associated with chronic alcohol use and withdrawal. However, not all biochemical abnormalities aligned with symptom severity, suggesting they are important for supportive management rather than severity prediction. 12 Therapeutic patterns (Table 6) revealed that diazepam (68.6%) was the most frequently prescribed benzodiazepine, supported by thiamine (86.6%) and normal saline (66.6%). These findings confirm that benzodiazepines remain the cornerstone of AWS treatment, while vitamin and fluid supplementation address common nutritional and metabolic deficits. 4 Interestingly, adjunct therapies such as antiepileptics were prescribed in 48% of patients, possibly reflecting the need for seizure prophylaxis in moderate-to-severe AWS cases.
5. Therapeutic strategies Effective management of Alcohol Withdrawal Syndrome (AWS) hinges on early identification, standardized severity assessment, and evidence-based therapeutic interventions. In this study, benzodiazepines—particularly diazepam and lorazepam—formed the cornerstone of pharmacologic therapy. 13 Diazepam was prescribed in 68.6% of cases, favoured for its long half-life and smoother coverage of withdrawal symptoms. Lorazepam, used in 18% of patients, is commonly preferred in individuals with hepatic impairment due to its shorter half-life and safer metabolic profile. 14 Adjuvant therapies, including thiamine supplementation (86.6%) and normal saline infusion (66.6%), were critical in addressing the nutritional and fluid-electrolyte deficiencies often found in chronic alcohol users. Thiamine administration is particularly important for preventing Wernicke’s encephalopathy, a potentially fatal complication of AWS. Intravenous fluids help stabilize hemodynamics , support renal function, and facilitate the clearance of accumulated toxins. Antiepileptic medications, such as phenytoin and valproic acid, were used in nearly 48% of patients, especially in those exhibiting moderate to severe withdrawal symptoms. These agents were initiated as a preventive measure against seizures, a known complication of unmonitored AWS progression. 15 The study also emphasizes the utility of the CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol– Revised) scale, which enables symptom-triggered therapy. Thirunanamoorthy et al. / Indian Journal of Pharmacy and Pharmacology 2025;12(3):137–143 142 This approach allows clinicians to administer benzodiazepines based on objective symptom scores rather than fixed schedules, reducing the risk of overmedication, excessive sedation, and respiratory depression. Studies have shown that symptom- triggered therapy can also reduce the length of hospital stay and improve overall patient outcomes. 16,17
6. In summary, a multimodal therapeutic strategy comprising,
7. Benzodiazepine administration guided by CIWA-Ar scores,
8. Nutritional support with thiamine and vitamins.
9. Intravenous fluid therapy for electrolyte and volume correction, and
10. Prophylactic antiepileptic use in high-risk cases. was associated with better symptom control and minimized complications. These strategies, supported by both our findings and published evidence, should be adopted as standard protocol in the management of AWS in hospital settings, especially in resource-limited environments.
11.  Conclusion This study highlights the clinical value of using the CIWA-Ar scale for structured evaluation and management of Alcohol Withdrawal Syndrome. The majority of patients exhibited moderate symptoms, with nausea, tremors, and anxiety being the most prevalent—though not severity-specific. Agitation and tactile disturbances were more predictive of severe AWS. A strong correlation was found between the time since last alcohol intake and withdrawal severity, reinforcing the importance of early history-taking. Although biochemical abnormalities such as hyponatremia and elevated liver enzymes were common, they were not consistent predictors of clinical severity. Benzodiazepines, especially diazepam and lorazepam, were found to be safe and effective for withdrawal control. Thiamine supplementation and IV fluids supported recovery and prevented complications such as Wernicke’s encephalopathy. Overall, early detection, standardized symptom scoring, and evidence-based therapeutic strategies are essential to improve patient outcomes. The findings from this study support the implementation of protocol-based AWS management in tertiary care settings, particularly in resource- limited environments.
12.  Author Contributions
13. Rengaraj Thirunanamoorthy: Supervised clinical execution at the hospital, ensured ethical compliance during data collection, and contributed to review and final approval of the manuscript.
14. Lakshmi Sabapathi Sundaram: Provided academic supervision and guidance throughout the research process, reviewed and critically revised the manuscript for important intellectual content.
15. Vignesh Sekar: Principal Investigator. Contributed to study conceptualization, literature review, data collection, data analysis and interpretation. Responsible for the integrity and accuracy of the entire work.
16. Vignesh Vaithiyanathan: Assisted in literature review, data interpretation, preparation of tables and figures. Mainly responsible for manuscript drafting and formatting.
17. Vilvarajeshwaran Balamurugan: Contributed to data collection in clinical settings, helped with case documentation and supported manuscript editing.
18.  Ethical Committee Approval This study was conducted after obtaining approval from the institutional ethical committee with proposal no. GMCN/ IEC/2024/1/36.
19.  Source of Funding None.
20.  Conflict of Interest None.
21.  Acknowledgements The success and culmination of this project were made possible through the invaluable guidance and assistance of numerous individuals, to whom we owe immense gratitude. We are grateful to our institutional guide, Dr. S. Lakshmi Sabapathi, Associate Professor, E.G.S. Pillay College of Pharmacy, for his guidance and support in the successful completion of our project work. We sincerely thank the Department of General Medicine, Government Medical College Hospital, Nagapattinam, for providing the necessary support to carry out this study. We also thank the patients and clinical staff for their cooperation which contributed to our successful completion of this project in time. References
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