Neurobiology and pharmacology
Chronic alcohol use enhances this inhibitory neurotransmitter system, leading to receptor downregulation.
GABA-A
Most common timeline for onset of withdrawal symptoms after last drink
6–24 hours
This medication reduces heavy drinking by modulating opioid receptors.
naltrexone
Most common psychiatric comorbidity with AUD
major depressive disorder
Best initial step in suspected Wernicke encephalopathy.
IV thiamine BEFORE glucose
This excitatory receptor becomes upregulated in chronic alcohol use, contributing to withdrawal seizures.
NMDA (glutamate receptor)
This is the most sensitive early sign of alcohol withdrawal.
tremor
This mechanism explains disulfiram’s aversive effect.
acetaldehyde accumulation due to aldehyde dehydrogenase inhibition
Alcohol is a major risk factor for this arrhythmia, sometimes called “holiday heart.”
Which electrolyte abnormality increases risk of arrhythmia during withdrawal and must be corrected.
a-fib
hypomagnesemia
Best medication for AUD with severe liver disease
acamprosate. (naltrexone is contraindicated)
Alcohol increases dopamine release in this pathway, reinforcing addictive behavior
mesolimbic pathway
Peak timing for Delirium Tremens.
48–96 hours
This medication restores glutamate balance and is safest in liver disease
acamprosate
Alcohol withdrawal seizures are typically of this type.
generalized tonic-clonic seizures
Two best meds for reducing heavy drinking (not necessarily abstinence)
naltrexone and topiramate
AST:ALT ratio typically seen in alcoholic liver disease
2:1
A patient with AUD develops visual hallucinations but remains oriented and stable vitals.
alcoholic hallucinosis
Off-label medication that reduces cravings via GABA modulation and is renally cleared
topiramate
This hematologic finding is classically associated with chronic alcohol use even without anemia.
macrocytosis (elevated MCV)
Two key risk factors for severe withdrawal.
prior DTs and high daily intake
Chronic alcohol exposure alters this ion channel, contributing to tolerance via neuronal hyperexcitability.
voltage-gated calcium channels
triad defines a neurologic emergency in alcohol use disorder and requires immediate treatment
confusion, ataxia, and ophthalmoplegia
This long-acting injectable improves adherence in patients with poor compliance.
extended-release naltrexone
AUD significantly increases risk for this type of cancer in the upper GI tract
esophageal squamous cell carcinoma
Two neurotransmitter systems most implicated in withdrawal pathophysiology
GABA (↓) and glutamate (↑)