The Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar; Sullivan et al., 1989) is the most commonly used rating scale for quantifying the severity of alcohol withdrawal, to monitor change in the severity, and, in the symptom-triggered treatment approach, to decide whether or not to give a dose of benzodiazepine to treat the withdrawal.
– It is based on both patient rating and clinician rating.
– It has only ten items and can be completed in about five minutes.
– It is well-established as a way of guiding symptom-triggered treatment of alcohol withdrawal.
– It is not copyrighted and can be freely copied and used.
You can download the scale as a pdf for use in your clinical practice by clicking on this link: CIWA-Ar
The CIWA-Ar is a ten-item scale. The ten items are nausea and vomiting, tremor, paroxysmal sweats, anxiety, tactile disturbances, auditory disturbances, visual disturbances, headache/fullness in the head, agitation, orientation/ clouding of the sensorium.
You will note that some items are evaluated only by asking the patient (e.g., headache/fullness in the head), some only by observation (e.g., tremor, paroxysmal sweats, agitation), and some by both asking the patient and observation (e.g., nausea and vomiting, anxiety).
The total score on the CIWA-Ar is simply a sum of the score on the individual items.
A higher total score on the CIWA-Ar indicates more severe withdrawal.
But, the original paper (Sullivan et al., 1989) did not give clear guidelines for interpreting the score as mild, moderate, severe, etc. So, different authors disagree a bit about the categories of mild, moderate, or severe withdrawal (e.g., Mirijello et al., 2015; Jesse et al., 2017). But, here are approximate categories of severity of alcohol withdrawal based on the CIWA-Ar total score:
9 or less: No withdrawal or mild withdrawal.
Note: More than either 8 or 10 can be taken as a cut-off to give a dose of benzodiazepine to treat alcohol withdrawal.
10 to 18: Moderate-to-severe withdrawal
> 18 Severe withdrawal with a risk of complications.
Which benzodiazepines for alcohol withdrawal syndrome (AWS)?
Alcohol withdrawal syndrome: Benzodiazepine regimens
Understanding the DSM-5 diagnostic criteria for alcohol withdrawal
Jesse S, Bråthen G, Ferrara M, Keindl M, Ben-Menachem E, Tanasescu R, Brodtkorb E, Hillbom M, Leone MA, Ludolph AC. Alcohol withdrawal syndrome: mechanisms, manifestations, and management. Acta Neurol Scand. 2017 Jan;135(1):4-16. Review. PubMed PMID: 27586815; PubMed Central PMCID: PMC6084325.
Mirijello A, D’Angelo C, Ferrulli A, Vassallo G, Antonelli M, Caputo F, Leggio L, Gasbarrini A, Addolorato G. Identification and management of alcohol withdrawal syndrome. Drugs. 2015 Mar;75(4):353-65. Review. PubMed PMID: 25666543; PubMed Central PMCID: PMC4978420.
Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM. Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). Br J Addict. 1989 Nov;84(11):1353-7. PubMed PMID: 2597811.
Copyright 2018, Rajnish Mago, MD. All rights reserved. May not be reproduced in any form without express written permission.
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