What is the initial step in managing alcohol withdrawal using the Clinical Institute Withdrawal Assessment (CIWA) protocol?

Initial Management of Alcohol Withdrawal Using CIWA Protocol

The initial step is to perform a CIWA assessment to quantify withdrawal severity, then immediately administer benzodiazepines for scores ≥8 using a symptom-triggered approach, with long-acting agents (diazepam or chlordiazepoxide) preferred for most patients. 1

Step 1: Perform CIWA Assessment

• The CIWA scoring system evaluates autonomic nervous system activation, gastrointestinal symptoms, and cognitive deficits to determine withdrawal severity 1
• Complete the assessment before initiating pharmacotherapy to establish a baseline severity score 2
• CIWA scores ≥8 indicate moderate withdrawal requiring benzodiazepine intervention 1
• CIWA scores ≥15 indicate severe withdrawal with significantly higher risk of complications including seizures and delirium 1, 3
• Patients scoring >15 have a 3.72-fold increased risk of severe withdrawal complications if left untreated 3

Step 2: Immediate Benzodiazepine Administration Based on Score

For Moderate Withdrawal (CIWA 8-14):

• Administer diazepam 5-10 mg every 6-8 hours as needed 1
• Alternatively, chlordiazepoxide 25-100 mg every 4-6 hours orally 4
• Long-acting benzodiazepines are preferred for seizure prevention through GABA activation 1, 4

For Severe Withdrawal (CIWA ≥15):

• More aggressive benzodiazepine dosing is required 1
• Consider loading dose technique: give diazepam every 1-2 hours initially until clinical improvement or mild sedation appears 2
• The loading dose approach with long half-life drugs typically prevents complications and rarely requires further therapy 2

Special Population Modifications:

• Use lorazepam 6-12 mg/day (1-4 mg every 4-8 hours) for patients with liver dysfunction, advanced age, respiratory compromise, recent head trauma, or obesity 1, 4, 5
• Lorazepam has safer pharmacokinetics in these populations despite lack of controlled trial evidence for superiority in liver disease 4, 5

Step 3: Mandatory Thiamine Administration

• Administer thiamine 100-300 mg/day to ALL patients with alcohol withdrawal immediately 1, 4, 5
• Thiamine deficiency is present in 30-80% of alcohol-dependent patients 5
• Give thiamine BEFORE any dextrose-containing solutions to prevent precipitating Wernicke encephalopathy 5
• Continue thiamine supplementation for 2-3 months following resolution of withdrawal symptoms 1

Step 4: Determine Treatment Setting

Inpatient Admission Required For:

• Seizures or delirium tremens 1, 5
• History of severe withdrawal symptoms or complicated withdrawal 1, 5
• Concurrent serious physical or psychiatric disorders 5
• Inadequate social support 5
• Malnutrition or suspected Wernicke's encephalopathy 5

Outpatient May Be Appropriate For:

• Patients without the above risk factors have similar 6-month abstinence rates with more cost-effective outpatient treatment 1

Critical Pitfalls to Avoid

• Do not use CIWA for diagnosis alone—high scores occur in anxiolytic withdrawal, anxiety disorders, sepsis, hepatic encephalopathy, and severe pain 1, 4
• Do not discontinue benzodiazepines prematurely based on day of admission—treat until complete symptom resolution, as withdrawal can persist beyond 72 hours 5
• Limit benzodiazepine treatment to 10-14 days maximum to prevent iatrogenic dependence 4, 5
• Do not use phenytoin or other anticonvulsants for withdrawal seizure prevention—they are ineffective and may worsen outcomes 5
• Do not use antipsychotics as monotherapy—they lower seizure threshold and should only be added to benzodiazepines for refractory delirium 5
• More than 70% of cirrhotic patients may not require pharmacological treatment—dose only when symptoms are present 5

Ongoing Monitoring

• Continue symptom-triggered dosing guided by serial CIWA-Ar scores throughout withdrawal 5
• Monitor for common complications: dehydration, electrolyte imbalances, gastrointestinal bleeding, pancreatitis, infection (especially pneumonia and spontaneous bacterial peritonitis in cirrhotics) 5
• Obtain psychiatric consultation for evaluation, acute management, and long-term abstinence planning 1, 5