CIWA-Ar Calculator
Clinical Institute Withdrawal Assessment for Alcohol - Revised. Quantify alcohol withdrawal severity and guide benzodiazepine dosing using 10 symptom categories.
Assess Each Symptom (0-7 scale)
1. Nausea and Vomiting
2. Tremor
3. Paroxysmal Sweats
4. Anxiety
5. Agitation
6. Tactile Disturbances
7. Auditory Disturbances
8. Visual Disturbances
9. Headache, Fullness in Head
10. Orientation and Clouding of Sensorium
Clinical Recommendation
💊 Benzodiazepine Dosing Guidance
Score Interpretation
| Score | Severity | Treatment | Monitoring |
|---|---|---|---|
| < 8 | Minimal/Absent | Usually no medication needed | Every 4-8 hours |
| 8-9 | Very Mild | Consider low-dose benzodiazepine | Every 2-4 hours |
| 10-15 | Mild-Moderate | Moderate-dose benzodiazepine | Every 1-2 hours |
| 16-20 | Moderate | Higher-dose benzodiazepine, consider ICU | Hourly |
| > 20 | Severe | Aggressive treatment, ICU recommended | Continuous monitoring |
Symptom-Triggered Therapy
Dosing based on CIWA-Ar scores reduces total benzodiazepine use and shortens treatment duration compared to fixed-schedule dosing. Assess hourly during active withdrawal.
Essential Adjuncts
All patients should receive thiamine 100 mg (before glucose), folic acid, multivitamin, magnesium replacement, and adequate hydration. These prevent Wernicke's encephalopathy and other complications.
About CIWA-Ar
The Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar) is the most widely used validated tool for assessing the severity of alcohol withdrawal syndrome and guiding pharmacological treatment with benzodiazepines.
Clinical Applications
- Objective quantification of alcohol withdrawal severity
- Guiding symptom-triggered benzodiazepine therapy
- Monitoring response to treatment and disease progression
- Identifying patients at high risk for severe withdrawal (DTs, seizures)
- Standardizing assessment across providers and institutions
Timeline of Alcohol Withdrawal
- 6-12 hours: Anxiety, tremor, sweating, nausea, increased heart rate
- 12-24 hours: Hallucinations may begin (usually visual)
- 24-48 hours: Peak risk for withdrawal seizures
- 48-72 hours: Delirium tremens (DTs) may develop in severe cases
- 5-7 days: Most symptoms resolve with appropriate treatment
Benzodiazepine Options
Common agents and typical dosing:
- Chlordiazepoxide (Librium): 25-100 mg PO q1-4h PRN. Long-acting, self-tapering.
- Lorazepam (Ativan): 1-4 mg PO/IV q1-4h PRN. Preferred in liver disease (no active metabolites).
- Diazepam (Valium): 5-20 mg PO/IV q1-4h PRN. Rapid onset, long-acting.
- Oxazepam (Serax): 15-30 mg PO q6h PRN. Short-acting, safer in elderly/liver disease.
Important Considerations
- CIWA-Ar should not be used in patients on regular benzodiazepines or alcohol
- Requires patient cooperation for accurate assessment
- Not appropriate for critically ill or intubated patients
- Treat underlying medical issues (infection, trauma, electrolyte abnormalities)
- Seizure prophylaxis is controversial; treat seizures if they occur
Frequently Asked Questions
How often should CIWA-Ar be assessed?
During active withdrawal, assess every 1-2 hours if score is ≥10, every 4 hours if score is <10. Continue assessments for at least 48-72 hours after last drink. Frequency may be reduced once patient is stable and scores are consistently low.
What is symptom-triggered versus fixed-schedule dosing?
Symptom-triggered therapy gives benzodiazepines only when CIWA-Ar score is ≥8-10, while fixed-schedule gives regular doses regardless of symptoms. Symptom-triggered therapy results in less total medication use and shorter treatment duration with equal safety.
Why is thiamine so important?
Thiamine (vitamin B1) prevents Wernicke's encephalopathy, a potentially fatal complication of alcohol use disorder. Give thiamine 100 mg IV/IM BEFORE any glucose-containing fluids, as glucose can precipitate Wernicke's in thiamine-deficient patients.
What are delirium tremens (DTs)?
DTs are the most severe form of alcohol withdrawal, typically occurring 48-96 hours after last drink. Features include severe confusion, hallucinations, autonomic instability (fever, tachycardia, hypertension), and agitation. Mortality is 5-15% even with treatment. Requires ICU care.
Which benzodiazepine is best?
For most patients: long-acting benzodiazepines (chlordiazepoxide, diazepam) are preferred as they self-taper. For liver disease or elderly: lorazepam or oxazepam (no active metabolites). For severe withdrawal: IV lorazepam or diazepam for rapid effect.
Can CIWA-Ar be used for other substance withdrawal?
No. CIWA-Ar is specifically designed and validated for alcohol withdrawal only. Other substances (benzodiazepines, opioids, etc.) require different assessment tools and management strategies.
What if benzodiazepines aren't controlling symptoms?
For benzodiazepine-refractory withdrawal, consider phenobarbital loading (10-15 mg/kg), propofol infusion (ICU setting), or dexmedetomidine as adjunct. Ensure adequate dosing of benzodiazepines before declaring refractoriness. Address other causes (infection, trauma, concurrent drug use).
Should I taper benzodiazepines after alcohol withdrawal?
With long-acting benzodiazepines and symptom-triggered therapy, formal taper is often unnecessary as the regimen is self-tapering. For patients requiring high total doses or prolonged treatment, a brief taper over 1-3 days may be appropriate. Avoid long-term benzodiazepines in alcohol use disorder.
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