How do you use the Clinical Institute Withdrawal Assessment (CIWA) protocol to treat alcohol withdrawal?

How to Use the CIWA Protocol to Treat Alcohol Withdrawal

Initial Assessment and CIWA-Ar Scoring

Use the Clinical Institute Withdrawal Assessment for Alcohol-revised (CIWA-Ar) scale to quantitatively assess withdrawal severity and guide symptom-triggered benzodiazepine dosing, with scores ≥8 indicating need for pharmacological treatment. 1, 2

• The CIWA-Ar is a 10-item scale that permits quantitative assessment of withdrawal symptoms and therapeutic response 2
• Administer the CIWA-Ar at baseline, then repeat every 1-2 hours initially during active withdrawal, and every 4-8 hours once symptoms stabilize 2, 3
• Scores <8 indicate mild withdrawal that may not require benzodiazepines—observe and reassess every 8 hours for 48 hours 3
• Scores 8-15 indicate moderate withdrawal requiring benzodiazepine treatment 1
• Scores ≥15 indicate severe withdrawal requiring aggressive treatment and close monitoring 1

Immediate Thiamine Administration

Administer thiamine 100-500 mg IV immediately BEFORE any glucose-containing fluids to prevent precipitating Wernicke encephalopathy. 4, 5

• Thiamine deficiency is present in 30-80% of alcohol-dependent patients 5
• Continue thiamine 100-300 mg/day throughout the withdrawal period and for 2-3 months following resolution 4, 5
• Never give dextrose-containing IV fluids before thiamine—this is a critical error that can trigger acute Wernicke encephalopathy 4, 5

Benzodiazepine Selection and Dosing

For most patients, initiate diazepam 10 mg orally every 1-2 hours until CIWA-Ar score drops below 8 or patient shows mild sedation (loading dose technique). 6, 2

• Long-acting benzodiazepines like diazepam provide superior protection against seizures and delirium tremens compared to shorter-acting agents 4, 1
• The FDA-approved dosing for acute alcohol withdrawal is diazepam 10 mg 3-4 times during the first 24 hours, reducing to 5 mg 3-4 times daily as needed 6
• The loading dose technique involves giving diazepam every 1-2 hours initially until clinical improvement occurs—if long half-life drugs are used, further therapy is rarely needed 2
• Alternative: chlordiazepoxide 50-100 mg orally initially, followed by 25-100 mg every 4-6 hours as needed (maximum 300 mg in first 24 hours) 4, 1

Special Populations Requiring Lorazepam

Switch to lorazepam 2-4 mg orally/IV every 4-6 hours (total 6-12 mg/day) in patients with hepatic dysfunction, advanced age, or respiratory compromise. 4, 5

• Lorazepam has safer pharmacokinetics in liver disease due to shorter half-life and no active metabolites 4, 5
• Despite widespread belief, the superiority of short-acting benzodiazepines in liver disease is not validated by controlled trials, and symptom-triggered dosing with diazepam can be safe when monitored appropriately 5
• Over 70% of cirrhotic patients may not require benzodiazepines at all—dose only when symptoms are present, not prophylactically 4, 5

Symptom-Triggered Dosing Algorithm

Reassess CIWA-Ar score 1 hour after each benzodiazepine dose and redose based on the following algorithm:

• CIWA-Ar <8: Hold benzodiazepines, reassess in 4-8 hours 3

• CIWA-Ar 8-15: Give diazepam 10 mg PO (or lorazepam 2 mg) and reassess in 1 hour 1, 2

• CIWA-Ar ≥15: Give diazepam 10-20 mg PO/IV (or lorazepam 2-4 mg IV) and reassess in 1 hour; consider ICU admission 4, 1

• Continue symptom-triggered dosing until CIWA-Ar remains <8 for 24 hours 2, 3

• Withdrawal symptoms typically peak at 3-5 days and resolve within one week 4

Management of Severe Withdrawal and Complications

For delirium tremens or severe withdrawal with CIWA-Ar ≥15 despite adequate benzodiazepines, escalate to IV diazepam 10 mg initially, followed by 5-10 mg every 3-4 hours. 4

• Monitor continuously for autonomic instability: tachycardia, hypertension, hyperthermia, sweating 4, 5
• Never use anticonvulsants (phenytoin, carbamazepine) to prevent alcohol withdrawal seizures—they are ineffective and may worsen outcomes 4, 5
• Benzodiazepines are the only proven treatment to prevent seizures and reduce mortality from delirium tremens 4, 5
• For refractory delirium tremens, add haloperidol as adjunct to benzodiazepines (never as monotherapy, as antipsychotics alone lower seizure threshold) 5

Essential Supportive Care

• Assess and correct dehydration, electrolyte imbalances (especially magnesium), and evaluate for concurrent complications: infection, GI bleeding, pancreatitis, hepatic encephalopathy 4, 5
• Magnesium is commonly depleted in chronic alcohol use and requires replacement 4
• Monitor for infection (pneumonia, spontaneous bacterial peritonitis in cirrhotics) which commonly complicates withdrawal 5

Duration and Tapering

Limit benzodiazepine treatment to 10-14 days maximum to prevent iatrogenic dependence. 5, 1

• After initial symptom control (typically 24-72 hours), begin gradual taper of long-acting benzodiazepines 4
• Do not discontinue benzodiazepines prematurely based on day of admission alone—treat until complete symptom resolution 5
• Continue symptom-triggered dosing guided by CIWA-Ar scores, as withdrawal symptoms can persist beyond 72 hours 5

Indications for Inpatient vs Outpatient Management

Admit to hospital if CIWA-Ar ≥15, history of withdrawal seizures or delirium tremens, significant comorbid medical/psychiatric illness, or failure of outpatient treatment. 4, 5

• Outpatient treatment is appropriate for mild-moderate withdrawal (CIWA-Ar 8-14) without complications, requiring daily physician visits for 3-5 days 4
• Patients with vomiting, tremor, or underlying liver disease require hospital admission 4

Post-Withdrawal Management

After stabilization, psychiatric consultation is mandatory for evaluation and long-term abstinence planning, including consideration of relapse prevention medications. 4, 5

• Offer acamprosate, naltrexone (if no severe liver disease), disulfiram, or baclofen for relapse prevention 5
• Baclofen up to 80 mg/day is safe in liver disease, though dose escalation should be gradual in severe hepatic dysfunction 5
• Avoid naltrexone and disulfiram in patients with alcoholic liver disease due to potential hepatotoxicity 5, 1

Common Pitfalls to Avoid

• Never administer glucose before thiamine 4, 5
• Never use anticonvulsants for alcohol withdrawal seizures 4, 5
• Never use antipsychotics as monotherapy—only as adjunct to benzodiazepines 5
• Never continue benzodiazepines beyond 10-14 days 5, 1
• Never assume all cirrhotic patients need benzodiazepines—over 70% may not require them 4, 5