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CIWA-Ar for Alcohol Withdrawal
CIWA-Ar
Empowering healthcare professionals with precision calculators and decision aids designed to improve care—right when it matters most.
CIWA-Ar for Alcohol Withdrawal
CIWA-Ar
Empowering healthcare professionals with precision calculators and decision aids designed to improve care—right when it matters most.
Instructions
The CIWA-Ar tool is used to assess alcohol withdrawal severity. Score each of the 10 items based on patient symptoms and clinical observation. Add the total score to guide management decisions.
Overview
When to use
Why use
Evidences
Interpretation
Score | Withdrawal Level |
≤ 8 | Absent or minimal withdrawal |
9 – 19 | Mild to moderate withdrawal |
≥ 20 | Severe withdrawal |
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;84(11):1353–1357. Introduced the 10‑item CIWA‑Ar, demonstrated strong inter‑rater reliability and correlation with withdrawal severity; proposed thresholds to guide symptom‑triggered benzodiazepine therapy.
https://pubmed.ncbi.nlm.nih.gov/2597811/
Daeppen JB, Gache P, Landry U, et al. Symptom‑triggered vs fixed‑schedule doses of benzodiazepine for alcohol withdrawal: a randomized treatment trial. Arch Intern Med. 2002;162(10):1117–1121. Symptom‑triggered oxazepam using CIWA‑Ar reduced total benzodiazepine dose and duration vs fixed schedule, with similar safety.
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/211434?resultClick=1
VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders (2021). Endorses symptom‑triggered regimens using CIWA‑Ar with monitoring protocols; includes thresholds for escalation and inpatient criteria.
https://www.healthquality.va.gov/guidelines/MH/sud/
NIAAA (NIH): Alcohol withdrawal overview and clinical resources; links to practice guidance emphasizing validated assessments and symptom‑triggered care where appropriate.https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/understanding-alcohol-use-disorder
Overview
When to use
Why use
Evidences
The CIWA-Ar is a structured clinical scale developed to quantify the severity of alcohol withdrawal and guide treatment. Alcohol withdrawal can present with a range of symptoms from mild anxiety and tremors to severe complications such as seizures and delirium tremens. Early recognition and appropriate intervention are critical to preventing morbidity and mortality.
The CIWA-Ar assesses 10 clinical features: nausea/vomiting, tremor, paroxysmal sweats, anxiety, agitation, tactile disturbances, auditory disturbances, visual disturbances, headache/fullness in head, and orientation/clouding of sensorium. Each item is scored from 0 to 7, except for orientation which is scored 0 to 4, producing a maximum total of 67 points.
Scoring helps clinicians determine the need for medical intervention. A score of less than 10 suggests minimal withdrawal and may not require pharmacological treatment. Scores between 10–18 indicate moderate withdrawal, and scores above 18 indicate severe withdrawal with an increased risk of seizures or delirium tremens.
Overview
When to use
Why use
Evidences
Interpretation
Score | Withdrawal Level |
≤ 8 | Absent or minimal withdrawal |
9 – 19 | Mild to moderate withdrawal |
≥ 20 | Severe withdrawal |
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;84(11):1353–1357. Introduced the 10‑item CIWA‑Ar, demonstrated strong inter‑rater reliability and correlation with withdrawal severity; proposed thresholds to guide symptom‑triggered benzodiazepine therapy.
https://pubmed.ncbi.nlm.nih.gov/2597811/
Daeppen JB, Gache P, Landry U, et al. Symptom‑triggered vs fixed‑schedule doses of benzodiazepine for alcohol withdrawal: a randomized treatment trial. Arch Intern Med. 2002;162(10):1117–1121. Symptom‑triggered oxazepam using CIWA‑Ar reduced total benzodiazepine dose and duration vs fixed schedule, with similar safety.
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/211434?resultClick=1
VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders (2021). Endorses symptom‑triggered regimens using CIWA‑Ar with monitoring protocols; includes thresholds for escalation and inpatient criteria.
https://www.healthquality.va.gov/guidelines/MH/sud/
NIAAA (NIH): Alcohol withdrawal overview and clinical resources; links to practice guidance emphasizing validated assessments and symptom‑triggered care where appropriate.https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/understanding-alcohol-use-disorder
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