What is the management approach for alcohol withdrawal using Clinical Institute Withdrawal Assessment (CIWA) scoring?

Management of Alcohol Withdrawal Using CIWA Scoring

Benzodiazepines administered using a symptom-triggered approach based on CIWA-Ar scoring is the gold standard treatment for alcohol withdrawal syndrome, with long-acting benzodiazepines preferred for most patients and short-acting options for those with hepatic dysfunction or elderly patients. 1, 2

Assessment and Severity Classification Using CIWA-Ar

• The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) is the standard tool for evaluating withdrawal severity:

  • Score <8: Mild withdrawal - observation only
  • Score 8-14: Moderate withdrawal - requires medication
  • Score ≥15: Severe withdrawal - requires aggressive treatment 1, 2

• CIWA-Ar assesses 10 symptoms including nausea/vomiting, tremor, sweating, anxiety, agitation, tactile/visual/auditory disturbances, headache, and orientation

• Important: CIWA-Ar should not be used alone for diagnosis as high scores may also occur in anxiety disorders, sepsis, hepatic encephalopathy, and severe pain 2

Treatment Algorithm Based on CIWA-Ar Scores

1. Mild Withdrawal (CIWA-Ar <8):

   • Monitor every 4-8 hours
   • No pharmacological intervention needed
   • Ensure adequate hydration and electrolyte balance

2. Moderate Withdrawal (CIWA-Ar 8-14):

   • Implement symptom-triggered benzodiazepine protocol
   • Reassess CIWA-Ar score every 2-4 hours
   • Can be managed in outpatient setting with close monitoring

3. Severe Withdrawal (CIWA-Ar ≥15):

   • Immediate benzodiazepine administration
   • Reassess CIWA-Ar score every 1-2 hours
   • Inpatient management required, especially with history of withdrawal seizures or delirium tremens 2

Benzodiazepine Selection and Dosing

• First-line options:

  • Long-acting benzodiazepines (preferred for most patients):

    • Diazepam: 5-10 mg PO/IV every 6-8 hours
    • Chlordiazepoxide: 25-100 mg PO every 4-6 hours

  • Short/intermediate-acting benzodiazepines (for elderly, hepatic dysfunction):

    • Lorazepam: 1-4 mg PO/IV/IM every 4-8 hours
    • Oxazepam: 15-30 mg PO every 6-8 hours 1, 2

• Symptom-triggered protocol:

  • Administer benzodiazepines based on CIWA-Ar scores
  • Results in lower total medication doses and shorter treatment duration compared to fixed-schedule dosing 2
  • Continue until CIWA-Ar scores remain <8 for 24 hours

Essential Adjunctive Therapies

• Thiamine supplementation:

  • Administer 100-300 mg/day to all AWS patients
  • Continue for 2-3 months following resolution of withdrawal symptoms
  • Prevents Wernicke encephalopathy 2

• Electrolyte replacement:

  • Correct magnesium, potassium, and phosphate deficiencies
  • Monitor glucose levels and treat hypoglycemia

• For agitation not controlled by benzodiazepines:

  • Haloperidol: 0.5-5 mg PO/IM every 8-12 hours
  • Note: Antipsychotics should not be used as standalone treatment for AWS 2

Special Considerations

• Patients with liver disease:

  • Use lorazepam or oxazepam instead of long-acting benzodiazepines
  • Monitor for oversedation and respiratory depression 1

• Delirium tremens (typically begins 48-72 hours after last drink):

  • Always requires inpatient management, often in ICU
  • Aggressive benzodiazepine treatment
  • IV fluids, electrolyte correction, and thiamine supplementation 2

• Withdrawal seizures:

  • Benzodiazepines are both treatment and prevention
  • Higher CIWA-Ar scores (>15) predict increased seizure risk 3

Post-Withdrawal Management

• Consider medications to prevent relapse (acamprosate, naltrexone, disulfiram)
• Refer to specialized addiction services and support groups
• Psychiatric consultation for evaluation and long-term planning 2

Monitoring Effectiveness

Studies show that using CIWA-Ar for symptom-triggered treatment results in:

• Reduced total benzodiazepine doses (mean dose 81.4 vs. 60.3 mg) 4
• No increase in complications when properly implemented 4, 5
• Earlier identification of patients at risk for severe withdrawal 3

The CIWA-Ar has been validated across multiple settings and languages, making it a reliable tool for managing alcohol withdrawal syndrome 6.