CIWA-Ar
Clinical Institute Withdrawal Assessment for Alcohol — revised
Calculator
Why use it
Standardizes alcohol withdrawal assessment. Enables symptom-triggered therapy (reduces total benzodiazepine use vs. fixed-dose schedules). Identifies patients at risk for severe withdrawal and delirium tremens.
About
The CIWA-Ar is a 10-item assessment tool used to quantify the severity of alcohol withdrawal and guide symptom-triggered benzodiazepine therapy. It evaluates nausea/vomiting, tremor, paroxysmal sweats, anxiety, agitation, tactile/auditory/visual disturbances, headache, and orientation. Scores guide dosing of benzodiazepines (typically chlordiazepoxide, lorazepam, or diazepam).
When to use
- Suspected or confirmed alcohol withdrawal
- Inpatient monitoring of alcohol withdrawal every 1-4 hours
- Guiding benzodiazepine dosing in withdrawal protocols
Formula
Pearls & pitfalls
- Symptom-triggered therapy (give benzos only when CIWA ≥ 10) is preferred over fixed-dose schedules.
- Assess CIWA every 1-4 hours during active withdrawal; increase frequency if scores rising.
- CIWA cannot be reliably used in intubated, sedated, or severely altered patients.
- Peak withdrawal typically occurs 24-72 hours after last drink; delirium tremens at 48-96 hours.
- Seizures can occur before CIWA scores are high — maintain clinical vigilance.
- Consider thiamine (100-500 mg IV) and folate supplementation in all alcohol withdrawal patients.
Next steps
Score < 10: Mild withdrawal, may not require medication. Score 10-18: Moderate withdrawal, initiate symptom-triggered benzodiazepines. Score > 20: Severe withdrawal, higher doses, consider ICU. Score > 35: Risk of seizures and delirium tremens, aggressive treatment.
Evidence
Developed by Sullivan et al. (Br J Addiction, 1989). Extensively validated. Symptom-triggered therapy shown to reduce treatment duration, total benzodiazepine dose, and ICU admissions (Saitz et al., JAMA 1994).