What is the Clinical Institute Withdrawal Assessment (CIWA) score of 15?

From the Guidelines

For a patient with a CIWA score of 15, I recommend starting benzodiazepine treatment immediately for alcohol withdrawal management, as indicated by the EASL clinical practice guidelines 1. The management of alcohol withdrawal syndrome (AWS) is crucial to prevent severe complications, and the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) score is a useful tool in clinical practice. A score ≥15 indicates severe AWS, and pharmacological treatment is recommended using a symptom-triggered regimen.

• Benzodiazepines are considered the 'gold standard' treatment for AWS, given their efficacy for reducing both withdrawal symptoms and the risk of seizures and/or delirium tremens 1.
• Long-acting benzodiazepines (e.g. diazepam, chlordiazepoxide) provide more protection against seizures and delirium, but short and intermediate-acting benzodiazepines (e.g. lorazepam, oxazepam) are safer in elderly patients and those with hepatic dysfunction 1.
• The treatment regimen should include lorazepam 2-4 mg orally or IV every 1-2 hours as needed, with reassessment of CIWA scores before each dose, or alternatively, diazepam 10-20 mg can be used following the same schedule.
• Close monitoring is required, with vital signs checked every 2-4 hours, and ensuring adequate hydration with IV fluids if the patient cannot maintain oral intake.
• Supplementing with thiamine 100 mg IV/IM daily for 3-5 days, followed by oral thiamine 100 mg daily, as well as providing folate 1 mg daily and a multivitamin, is also essential.
• Monitoring for worsening symptoms that might indicate progression to severe withdrawal or delirium tremens is crucial, and an aggressive early treatment approach is necessary because alcohol withdrawal is progressive and can rapidly worsen to life-threatening complications 1.

From the Research

CIWA 15 Overview

• The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) is a widely used scale for assessing the severity of alcohol withdrawal symptoms 2.
• The CIWA scale streamlines care, optimizes patient management, and is considered the best scale available for withdrawal assessment 2.

Benzodiazepines in Alcohol Withdrawal Treatment

• Benzodiazepines are considered the gold standard for treating alcohol withdrawal symptoms, with the largest and best evidence base 3.
• Different benzodiazepines, such as lorazepam, chlordiazepoxide, oxazepam, and diazepam, are commonly used for this purpose 4.
• Diazepam has been suggested as the preferred benzodiazepine for treating moderate to severe alcohol withdrawal due to its rapid onset of action and long elimination half-life 4.

Assessment and Treatment Protocols

• Symptom-triggered dosing of benzodiazepines is often preferred over fixed-schedule dosing, as it allows for more tailored treatment and can reduce the risk of over-sedation 2, 5.
• The CIWA-Ar score is a useful tool for assessing the severity of alcohol withdrawal symptoms and guiding treatment decisions 5.

Comparison of Treatment Options

• Benzodiazepines have been shown to be effective in reducing the severity of alcohol withdrawal symptoms, including seizures and delirium tremens 3, 5.
• Other medications, such as beta-blockers and anticonvulsants, may also be used in the treatment of alcohol withdrawal, but their effectiveness is less well established 6, 5.