Should this patient be on Clinical Institute Withdrawal Assessment (CIWA) protocol given a daily consumption of 6 ciders?

From the Guidelines

Yes, a patient drinking 6 ciders per day should be considered for CIWA protocol monitoring when discontinuing alcohol. This level of daily alcohol consumption puts the patient at risk for developing alcohol withdrawal syndrome when they stop drinking, as indicated by the EASL clinical practice guidelines 1. The CIWA protocol involves regular assessment of withdrawal symptoms using a standardized scale, with medication administration based on symptom severity.

Key Considerations

• The patient's daily alcohol consumption of 6 ciders is approximately equivalent to 6 standard drinks, which is a significant amount that can lead to alcohol dependence and withdrawal symptoms upon cessation.
• The CIWA-Ar score is a useful tool in clinical practice to assess the severity of alcohol withdrawal syndrome, with a score >8 indicating moderate AWS and a score ≥15 indicating severe AWS 1.
• Benzodiazepines, such as diazepam or lorazepam, are considered the 'gold standard' treatment for AWS, given their efficacy in reducing withdrawal symptoms and the risk of seizures and/or delirium tremens 1.

Treatment Approach

• The CIWA protocol allows for symptom-triggered dosing rather than fixed dosing, which can reduce overall medication requirements and length of treatment.
• Regular vital sign monitoring is also essential, as withdrawal can cause dangerous elevations in heart rate and blood pressure.
• The choice of benzodiazepine may depend on the patient's individual characteristics, such as age and liver function, with long-acting benzodiazepines providing more protection against seizures and delirium, but short and intermediate-acting benzodiazepines being safer in elderly patients and those with hepatic dysfunction 1.

From the FDA Drug Label

Symptomatic Relief in Acute Alcohol Withdrawal. 10 mg, 3 or 4 times during the first 24 hours, reducing to 5 mg, 3 or 4 times daily as needed

The patient's consumption of 6 ciders a day may indicate a risk of alcohol withdrawal. The CIWA protocol is typically used to manage alcohol withdrawal symptoms.

• The dosage of diazepam for symptomatic relief in acute alcohol withdrawal is provided, but it does not directly state whether a patient drinking 6 ciders a day should be on the CIWA protocol.
• However, given the patient's daily alcohol consumption, it is likely that they may experience alcohol withdrawal symptoms if they suddenly stop drinking.
• Therefore, it may be prudent to consider the CIWA protocol for this patient, but the decision should be made on a case-by-case basis, taking into account the patient's overall health and medical history 2.

From the Research

Patient Eligibility for CIWA Protocol

To determine if a patient drinking 6 ciders a day should be on a CIWA protocol, we need to consider the severity of their alcohol withdrawal symptoms.

• The CIWA-Ar scale is a widely used tool to assess the severity of alcohol withdrawal syndrome (AWS) 3, 4, 5, 6.
• Studies have shown that the CIWA-Ar protocol can be effective in managing AWS, reducing the average daily and cumulative dose of benzodiazepines, and decreasing the length of hospital stay 3, 6.
• However, the decision to place a patient on a CIWA protocol should be based on individual assessment of their risk factors for AWS, ability to communicate, and recent alcohol use 4.

Assessment of Alcohol Withdrawal Risk Factors

• The patient's daily consumption of 6 ciders may indicate a risk of AWS, but the decision to start a CIWA protocol should be based on a comprehensive assessment of their overall health and medical history 4.
• The CIWA-Ar scale assesses various symptoms, including nausea, tremors, and anxiety, to determine the severity of AWS 3, 5.
• A systematic review-based meta-analysis found that the CIWA-Ar total scores can follow the course of AWS and compare the effectiveness of benzodiazepine and non-benzodiazepine therapies 5.

Clinical Considerations

• The patient's ability to communicate and their recent alcohol use should be taken into account when deciding to start a CIWA protocol 4.
• The CIWA-Ar protocol should be used judiciously, with mechanisms in place to ensure assessment of validated alcohol withdrawal risk factors and continuity of care during transitions 4.
• A hospital-wide symptom-based alcohol withdrawal protocol may result in significant clinical improvements to patient outcomes, safety, and hospital efficiency 6.