CIWA-Ar for Alcohol Withdrawal
The CIWA-Ar objectifies severity of alcohol withdrawal.
- The Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) scale has ten items, each evaluated independently then aggregated to yield a score correlating with severity of alcohol withdrawal.
- There is no absolute relationship between alcohol use pattern and risk of physiologic dependence or withdrawal for a given individual. In general, any suspicion of daily alcohol use over several weeks or more, regardless of quantity, should raise concern for potential alcohol withdrawal.
- Additional variables that may contribute to risk include age, medical comorbidities like hepatic dysfunction, concomitant medication use, and low seizure threshold (Roffman JL 2006).
- The CIWA-Ar provides an efficient (<5 mins) and objective means of assessing alcohol withdrawal that can then be utilized in treatment protocols.
- Patients frequently under-report alcohol use and physicians often overlook alcohol problems in patients (Kitchens JM 1994). It is estimated that 1 of every 5 patients admitted to a hospital abuses alcohol (Schuckit 2001).
- Unrecognized alcohol withdrawal can lead to potentially life-threatening consequences including seizures and delirium tremens.
ADVICE
- Benzodiazepines are generally used to control psychomotor agitation and prevent progression to more severe withdrawal.
- DiazePAM (Valium), LORazepam (Ativan), and chlordiazePOXIDE (Librium) are the most frequently used benzodiazepines. Follow your hospital’s own alcohol withdrawal protocol; frequently treatment begins with benzodiazepines when CIWA-Ar scores reach 8-10, with standing or as needed dosing for scores 10-20. Some protocols even include transfer to the ICU for scores >20.
- Consider additional supportive care, including intravenous fluids, nutritional supplementation, and frequent clinical reassessment including vital signs.
MANAGEMENT
Assessment protocols utilizing CIWA-Ar vary and include medication dosing triggered by symptoms only and combined symptom-triggered + fixed-dose medication dosing.
CRITICAL ACTIONS
Other conditions can mimic or coexist with alcohol withdrawal, including:
- Drug overdose.
- Trauma (eg, intracranial hemorrhage).
- Infection (eg, meningitis).
- Metabolic derangements.
- Hepatic failure.
- Gastrointestinal bleeding.
Consider additional testing to rule out alternative diagnoses, especially if presentation includes altered mental status and/or fever.
FORMULA
Addition of the selected points.
FACTS & FIGURES
| Score | Withdrawal Level |
|---|---|
| ≤8 | Absent or minimal withdrawal |
| 9-19 | Mild to moderate withdrawal |
| ≥20 | Severe withdrawal |
EVIDENCE APPRAISAL
Superior clinical endpoints include:
- Decreased frequency of oversedation in patients with milder alcohol withdrawal.
- Decreased frequency of under-treatment in patients with greater severity of withdrawal.
- Shorter periods of hospitalization.
- Lower incidence of delirium tremens (Wartenburg 1990, Saitz 1994, Mayo-Smith 1997, Reoux 2000, Jaeger 2001, Nuss 2004
There is also some evidence for combined symptom-triggered and fixed-schedule treatment utilizing CIWA-Ar (Daeppen 2002).
The original CIWA-A, published by Shaw et al in 1981, was developed to assess the severity of alcohol withdrawal, both to monitor response to treatment and for use in research. The CIWA-Ar developed by Sullivan et al (1989) eliminated several redundant and ineffective items to increase the scale’s efficiency while retaining clinical usefulness, validity and reliability. This article proposes the CIWA-Ar scale as a shortened version of the original CIWA-A scale.
Reoux and colleagues compared routine hospital alcohol detoxification practice with CIWA-Ar-based as-needed protocol in a retrospective chart review and found fewer total chlordiazepoxide milligram equivalents used over a shorter duration with utilization of CIWA-Ar.
Literature
ORIGINAL/PRIMARY REFERENCE
Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM. Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). Br J Addict. 1989 Nov;84(11):1353-7. PubMed PMID: 2597811.
VALIDATION
Reoux JP, Miller K. Routine hospital alcohol detoxification practice compared to symptom triggered management with an Objective Withdrawal Scale (CIWA-Ar). Am J Addict. 2000;9:135–44. PubMed PMID: 10934575.
OTHER REFERENCES
Shaw JM, Kolesar GS, Sellers EM, Kaplan HL, Sandor P. Development of optimal treatment tactics for alcohol withdrawal. I. Assessment and effectiveness of supportive care. J Clin Psychopharmacol. 1981;1(6):382-389.
Wartenberg AA, Nirenberg TD, Liepman MR, Silvia LY, Begin AM, Monti PM. Detoxification of alcoholics: improving care by symptom-triggered sedation. Alcohol Clin Exp Res. 1990 Feb;14(1):71-5.
Kitchens JM. Does this patient have an alcohol problem? JAMA. 1994 Dec 14;272(22):1782-7.
Saitz R, Mayo-Smith MF, Roberts MS, et al. Individualized treatment for alcohol withdrawal. A randomized double-blind controlled trial. JAMA 1994; 272:519.
Bird RD, Makela EH. Alcohol withdrawal: what is the benzodiazepine of choice? Ann Pharmacother 1994; 28:67.
Mayo-Smith MF. Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal. JAMA. 1997 Jul 9;278(2):144-51.
Schuckit M. Alcohol and alcoholism. In: Brunwald E, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL. Harrison’s Principles of Internal Medicine.Vol. 2. 15th ed. New York, NY: McGraw-Hill Professional Publishing; 2001:2561–2566.
Jaeger TM, Lohr RH, Pankratz VS. Symptom-triggered therapy for alcohol withdrawal syndrome in medical inpatients. Mayo Clin Proc 2001; 76:695.
Daeppen JB, Gache P, Landry U, et al. Symptom-triggered vs fixed-schedule doses of benzodiazepine for alcohol withdrawal: a randomized treatment trial. Arch Intern Med 2002; 162:1117.
Nuss MA, Elnicki DM, Dunsworth TS, Makela EH. Utilizing CIWA-Ar to assess use of benzodiazepines in patients vulnerable to alcohol withdrawal syndrome. W V Med J. 2004 Jan-Feb;100(1):21-5.
Roffman JL, Stern TA. Alcohol Withdrawal in the Setting of Elevated Blood Alcohol Levels. Primary Care Companion to The Journal of Clinical Psychiatry. 2006;8(3):170-173.
Ng K, Dahri K, Chow I, Legal M. Evaluation of an alcohol withdrawal protocol and a preprinted order set at a tertiary care hospital. Can J Hosp Pharm. 2011 Nov;64(6):436-45.
