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    CIWA-Ar for Alcohol Withdrawal

    Objectifies alcohol withdrawal severity to help guide therapy.
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    Patients in a variety of settings, including outpatient, emergency, psychiatric, and general medical-surgical units, for whom there is clinical concern for 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.
    • Cannot be used effectively in intubated/sedated patients. A sedation scale such as the Richmond Agitation-Sedation Scale (RASS) is more appropriate in this setting.
    • 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.

    Result:

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    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

    Literature

    Other References

    Research PaperKitchens JM. Does this patient have an alcohol problem? JAMA. 1994 Dec 14;272(22):1782-7. PubMed PMID: 7966928.Research PaperSchuckit 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.Research PaperRoffman 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. PubMed PMID: 16912820.Research PaperWartenberg 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. PubMed PMID: 2178476.Research PaperNuss 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. PubMed PMID: 15119493.Research PaperMayo-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. PubMed PMID: 9214531.Research PaperSaitz R, Mayo-Smith MF, Roberts MS, et al. Individualized treatment for alcohol withdrawal. A randomized double-blind controlled trial. JAMA 1994; 272:519. PubMed PMID: 8046805.Research PaperJaeger TM, Lohr RH, Pankratz VS. Symptom-triggered therapy for alcohol withdrawal syndrome in medical inpatients. Mayo Clin Proc 2001; 76:695. PubMed PMID:11444401.Research PaperDaeppen 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. PubMed PMID:12020181.Research PaperNg 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. PubMed PMID: 22479099.Research PaperBird RD, Makela EH. Alcohol withdrawal: what is the benzodiazepine of choice? Ann Pharmacother 1994; 28:67.PubMed PMID:8123967.
    Dr. Edward M. Sellers

    About the Creator

    Edward M. Sellers, MD, PhD, FRCPC, FACP, is the president and principal of DL Global Partners Inc., which specializes in clinical psychopharmacology and pharmacogenetics for substance abuse. He is also professor emeritus at the University of Toronto and helped establish its clinical psychopharmacology unit. Dr. Sellers has received several awards for his research in pharmacology and drug dependence, including the Rawls-Palmer Award given by the ASCPT.

    To view Dr. Edward M. Sellers's publications, visit PubMed