What is the typical Clinical Institute Withdrawal Assessment (CIWA) protocol for managing alcohol withdrawal symptoms?

The CIWA Protocol for Alcohol Withdrawal Management

The typical CIWA (Clinical Institute Withdrawal Assessment for Alcohol) protocol involves using a symptom-triggered approach with benzodiazepines as first-line treatment, guided by CIWA-Ar scores that categorize withdrawal severity as mild (<8), moderate (8-14), or severe (≥15). 1

Assessment Using CIWA-Ar Scale

The CIWA-Ar scale evaluates the severity of alcohol withdrawal symptoms through assessment of:

• Nausea/vomiting
• Tremor
• Paroxysmal sweats
• Anxiety
• Agitation
• Tactile disturbances
• Auditory disturbances
• Visual disturbances
• Headache/fullness in head
• Orientation and clouding of sensorium

Each item is scored, with a total score determining the severity of withdrawal and guiding treatment decisions.

Treatment Protocol Based on CIWA-Ar Scores

Mild Withdrawal (CIWA-Ar <8)

• Monitor regularly
• Supportive care
• No medication typically required

Moderate Withdrawal (CIWA-Ar 8-14)

• Symptom-triggered benzodiazepine therapy
• Diazepam 5-10 mg PO/IV every 6-8 hours or
• Lorazepam 1-4 mg PO/IV/IM every 4-8 hours
• Reassess with CIWA-Ar every 1-2 hours

Severe Withdrawal (CIWA-Ar ≥15)

• Immediate benzodiazepine treatment
• Diazepam 10 mg IV for severe agitation or
• Lorazepam 2-4 mg IV for severe symptoms or seizures
• Consider inpatient admission
• Frequent monitoring of vital signs
• Reassess with CIWA-Ar every hour until stable

Medication Selection

For Normal Liver Function

• Long-acting benzodiazepines preferred:
  • Diazepam (5-10 mg PO/IV every 6-8 hours)
  • Chlordiazepoxide (25-100 mg PO every 4-6 hours)

For Liver Dysfunction, Advanced Age, or Serious Comorbidities

• Intermediate-acting benzodiazepines preferred:
  • Lorazepam (1-4 mg PO/IV/IM every 4-8 hours)
  • Starting dose: 6-12 mg/day, tapered following resolution of symptoms 2, 1

Supportive Care

• Thiamine supplementation: 100-300 mg/day for all AWS patients (administer before glucose-containing IV fluids)
• Continue thiamine: For 2-3 months after withdrawal resolution
• IV fluids: Normal saline to correct dehydration
• Electrolyte monitoring and correction: Particularly potassium, magnesium, and phosphate 1

Monitoring Protocol

• For moderate withdrawal: Reassess with CIWA-Ar every 1-2 hours
• For severe withdrawal: Reassess with CIWA-Ar hourly until stable
• Monitor vital signs frequently, especially with severe withdrawal

Important Considerations and Pitfalls

• The CIWA protocol is helpful for evaluating AWS severity and treatment planning, but should not be used alone for diagnosis 2
• High CIWA scores may also occur in anxiety disorders, sepsis, hepatic encephalopathy, and severe pain 1
• Antipsychotics should not be used as standalone treatment for AWS as they may lower seizure threshold 1
• Inpatient treatment is recommended for cases with serious complications such as alcohol withdrawal delirium or seizures 2
• Psychiatric consultation is recommended for evaluation, treatment, and long-term planning of alcohol abstinence 2

Alternative Assessment Tools

Some institutions have developed shorter assessment tools that may be more feasible in certain settings:

• The SHOT scale (Sweating, Hallucinations, Orientation, and Tremor) takes approximately 1 minute to complete versus 5 minutes for CIWA-Ar 3
• The Brief Alcohol Withdrawal Scale (BAWS) is a 5-item scale that has shown good correlation with CIWA-Ar 4

However, the CIWA-Ar remains the most widely validated and used assessment tool for alcohol withdrawal management.