What is the protocol for managing alcohol withdrawal in a patient using the Clinical Institute Withdrawal Assessment (CIWA) scale?

CIWA-Based Alcohol Withdrawal Management Protocol

Critical Limitation of CIWA

The CIWA protocol is NOT recommended for diagnosing alcohol withdrawal syndrome and should only be used to guide treatment intensity in patients with confirmed AWS. 1

• CIWA scores can be falsely elevated in psychiatric conditions (anxiolytic withdrawal, anxiety disorder) and medical conditions (sepsis, hepatic encephalopathy, severe pain), making it unreliable for diagnosis 1
• Always confirm AWS clinically based on timing (6-24 hours after last drink), autonomic symptoms (tachycardia, sweating, tremor), and drinking history before using CIWA 1

CIWA-Guided Treatment Algorithm

Initial Assessment and Scoring

• Administer CIWA-Ar every 1-2 hours during acute withdrawal phase 2
• CIWA-Ar ≥10 indicates need for benzodiazepine treatment 3
• CIWA-Ar ≥15 indicates severe AWS requiring aggressive management 2, 4
• CIWA-Ar <10 allows safe observation with repeat scoring every 8 hours for 48 hours 3

Pharmacological Management Based on CIWA Score

For CIWA-Ar ≥10 (Moderate Withdrawal):

• Initiate long-acting benzodiazepines: chlordiazepoxide 25-100 mg PO every 4-6 hours OR diazepam 5-10 mg PO/IV every 6-8 hours 1, 2
• Reassess CIWA-Ar every 1-2 hours and dose benzodiazepines based on ongoing scores 2
• Continue symptom-triggered dosing until CIWA-Ar remains <8-10 for 24 hours 5

For CIWA-Ar ≥15 (Severe Withdrawal):

• Initiate higher-dose benzodiazepines: chlordiazepoxide 50-100 mg PO initially, then 25-100 mg every 4-6 hours (maximum 300 mg in first 24 hours) 6
• Consider IV diazepam 10 mg initially, followed by 5-10 mg every 3-4 hours for severe AWS with altered consciousness 6
• Admit to inpatient setting for continuous monitoring 1, 2

Special Populations Requiring Lorazepam:

• Switch to lorazepam 1-4 mg PO/IV/IM every 4-8 hours (starting dose 6-12 mg/day) for patients with: 1, 2
  • Hepatic dysfunction or liver failure
  • Advanced age
  • Recent head trauma
  • Respiratory failure
  • Obesity
  • Other serious medical comorbidities

Mandatory Adjunctive Treatment (Regardless of CIWA Score)

Thiamine Administration:

• Give thiamine 100-300 mg/day BEFORE any glucose-containing IV fluids to prevent Wernicke encephalopathy 1, 6, 2
• For high-risk patients or suspected Wernicke's: thiamine 100-500 mg IV immediately 6
• Continue thiamine 100-300 mg/day for 2-3 months after withdrawal resolution 1

Supportive Care:

• Fluid and electrolyte replacement with careful attention to magnesium levels 1, 6
• Frequent vital sign monitoring for autonomic instability 1, 6

Treatment Duration and Tapering

• Begin tapering benzodiazepines after CIWA-Ar remains consistently <8-10 1
• Do not continue benzodiazepines beyond 10-14 days due to abuse potential 6, 5, 2
• Taper gradually over several days after symptom resolution 1

Indications for Inpatient vs Outpatient Management

Admit to Hospital if:

• CIWA-Ar ≥15 or significant withdrawal symptoms 1, 2
• History of withdrawal seizures or delirium tremens 1, 2
• High levels of recent drinking 1
• Co-occurring serious medical illness (liver disease, infection, pancreatitis) or psychiatric illness 1, 2
• Failure of outpatient treatment 1

Outpatient Management Appropriate if:

• CIWA-Ar <15 with mild-moderate symptoms 6
• No history of complicated withdrawal 6
• Adequate social support and ability to attend daily monitoring 6
• No serious medical/psychiatric comorbidities 6

Critical Pitfalls to Avoid

• Never use CIWA alone to diagnose AWS—confirm clinically first 1
• Never give glucose-containing IV fluids before thiamine—this precipitates acute Wernicke encephalopathy 1, 6
• Do not use anticonvulsants (phenytoin, carbamazepine) for alcohol withdrawal seizures—benzodiazepines are the only proven treatment 1, 5
• Do not continue benzodiazepines beyond 10-14 days—risk of iatrogenic dependence 6, 5, 2
• Do not discontinue benzodiazepines prematurely based on day of admission—treat until symptom resolution 5
• Over 70% of cirrhotic patients may not require benzodiazepines at all—dose only when CIWA-Ar indicates symptoms are present 5

Post-Acute Management

Mandatory psychiatric consultation for: 1, 6, 2

• Comprehensive evaluation of alcohol use disorder
• Acute AWS management guidance
• Long-term abstinence planning

Consider relapse prevention medications after stabilization: 6, 5, 2

• Acamprosate (safe in liver disease)
• Naltrexone (avoid in severe liver disease due to hepatotoxicity)
• Baclofen (safe in liver disease, up to 80 mg/day)
• Topiramate