From the Guidelines
CIWA monitoring can be safely discontinued when a patient has achieved a low risk of withdrawal, as indicated by a CIWA-Ar score ≤8, and has been stable for at least 24 hours without requiring any as-needed benzodiazepines. This recommendation is based on the management of alcohol withdrawal syndrome guidelines, which suggest that a CIWA-Ar score >8 indicates a moderate AWS and a score ≥15 indicates severe AWS 1.
Key Considerations for Discontinuing CIWA Monitoring
- The patient should demonstrate clinical stability with normal vital signs, particularly without tachycardia or hypertension that would suggest ongoing withdrawal.
- The patient should be eating and sleeping normally, show no signs of confusion or agitation, and have no tremors.
- Typically, this occurs 48-72 hours after the last drink for uncomplicated alcohol withdrawal, though monitoring may need to continue longer (5-7 days) for patients with a history of severe withdrawal, seizures, or delirium tremens.
Rationale for Discontinuing CIWA Monitoring
The physiological basis for this recommendation is that alcohol withdrawal symptoms typically peak within 24-48 hours after the last drink as GABA inhibition decreases and glutamate excitation increases in the brain 1. Once this neurochemical imbalance begins to normalize, withdrawal symptoms subside, making continued intensive monitoring unnecessary. However, patients should still be observed for post-acute withdrawal symptoms which may persist for weeks.
Additional Considerations
- Benzodiazepines, the 'gold standard' treatment for AWS, should be used for a limited period (10-14 days) to avoid the risk of abuse, particularly in patients with AUD 1.
- Other drugs, such as baclofen and sodium oxybate, have been tested in the treatment of AWS and may have additional value in treating AUD 1.
From the Research
CIWA Monitoring Discontinuation
- CIWA monitoring can be discontinued when the patient's score is less than 10, as studies have shown that scores below this threshold do not require benzodiazepine treatment 2.
- A study published in 2004 found that using the CIWA-Ar to assess patients vulnerable to alcohol withdrawal syndrome allowed for the safe withholding of detoxification regimens in 9 out of 16 patients with initial CIWA-Ar scores less than 10 2.
- However, the decision to discontinue CIWA monitoring should be made on a case-by-case basis, taking into account the individual patient's symptoms and response to treatment.
- It is also important to note that CIWA monitoring is typically used in conjunction with other treatment protocols, such as benzodiazepine therapy, and discontinuation of monitoring should be done in accordance with established treatment guidelines 3, 4.
- Some studies suggest that alternative treatment modalities, such as phenobarbital or anticonvulsants, may be effective in treating alcohol withdrawal syndrome and could potentially reduce the need for CIWA monitoring 5, 4, 6.