CIWA-Ar for Alcohol Withdrawal

id

1736

full_title

CIWA-Ar for Alcohol Withdrawal

short_title

CIWA-Ar

med_description

The CIWA-Ar objectifies severity of alcohol withdrawal.

description

The CIWA-Ar for Alcohol Withdrawal objectifies severity of alcohol withdrawal symptoms.

keywords

alcohol withdrawal severity, etoh seizure severity, CIWA, withdrawal severity, etoh withdrawal score, withdrawal symptoms score, alcoholism severity, alcoholism severuty score, withdrawal etoh score, withdrawal etoh calc, etoh ciwa, ciwa calc, ciwa score, ciwa mdcalc, ciwa-ar calc, cwa-ar, ciwa-ar score, withdrawal severity, withdrawal severity score, withdrawal alcohol score, withdrawal alcohol severity, withdrawal alcoholics, ciwa alcoholics, ciwa alcoholism, objectify alcohol sx, objectify alcoholic sx, objectify withdrawal, objectify withdrawal sx, objectify withdrawal alcohol, objectify withdrawal etoh, objectify withdrawal alc, objectify w/d sx, objectify w/d, objectify w/d symptoms, objectify w/d sx, objectify w/d etoh, objectify w/d alc sx, withdrawal ar, withdrawal symptom severity, sx severity alc withdrawal, sx severity etoh withdrawal

complaint

[ "Agitation", "Anxious", "Fever", "Headache", "Intoxication/Overdose", "Loss of Appetite", "Nausea", "Seizure", "Vomiting" ]

formula

Addition of the selected points.

evidence

Multiple randomized trials and observational studies support use of symptom-triggered treatment (using CIWA-Ar) over fixed-schedule treatment (in which benzodiazepines are given at fixed intervals) or vitals-triggered treatment.

Superior clinical endpoints include:

• Decreased frequency of oversedation in patients with milder alcohol withdrawal.

• Decreased frequency of under-treatment in patients with greater severity of withdrawal.

• Shorter periods of hospitalization.

• Lower incidence of delirium tremens (Wartenburg 1990, Saitz 1994, Mayo-Smith 1997, Reoux 2000, Jaeger 2001, Nuss 2004).

There is also some evidence for combined symptom-triggered and fixed-schedule treatment utilizing CIWA-Ar (Daeppen 2002).

The original CIWA-A, published by Shaw et al in 1981, was developed to assess the severity of alcohol withdrawal, both to monitor response to treatment and for use in research. The CIWA-Ar developed by Sullivan et al (1989) eliminated several redundant and ineffective items to increase the scale’s efficiency while retaining clinical usefulness, validity and reliability. This article proposes the CIWA-Ar scale as a shortened version of the original CIWA-A scale.

Reoux and colleagues compared routine hospital alcohol detoxification practice with CIWA-Ar-based as-needed protocol in a retrospective chart review and found fewer total chlordiazepoxide milligram equivalents used over a shorter duration with utilization of CIWA-Ar.

measurements

[]

information

refrences

{ "Clinical Practice Guidelines": [], "Manufacturer Website": [], "Original/Primary Reference": [ { "href": "https://www.ncbi.nlm.nih.gov/pubmed/2597811", "text": "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." } ], "Other References": [ { "href": "https://pubmed.ncbi.nlm.nih.gov/7334148/", "text": "Shaw JM, Kolesar GS, Sellers EM, Kaplan HL, Sandor P. Development of optimal treatment tactics for alcohol withdrawal. I. Assessment and effectiveness of supportive care. J Clin Psychopharmacol. 1981;1(6):382-389." }, { "href": "https://www.ncbi.nlm.nih.gov/pubmed/2178476", "text": "Wartenberg AA, Nirenberg TD, Liepman MR, Silvia LY, Begin AM, Monti PM. Detoxification of alcoholics: improving care by symptom-triggered sedation. Alcohol Clin Exp Res. 1990 Feb;14(1):71-5." }, { "href": "https://www.ncbi.nlm.nih.gov/pubmed/7966928", "text": "Kitchens JM. Does this patient have an alcohol problem? JAMA. 1994 Dec 14;272(22):1782-7." }, { "href": "https://www.ncbi.nlm.nih.gov/pubmed/?term=8046805", "text": "Saitz R, Mayo-Smith MF, Roberts MS, et al. Individualized treatment for alcohol withdrawal. A randomized double-blind controlled trial. JAMA 1994; 272:519." }, { "href": "https://www.ncbi.nlm.nih.gov/pubmed/?term=8123967", "text": "Bird RD, Makela EH. Alcohol withdrawal: what is the benzodiazepine of choice? Ann Pharmacother 1994; 28:67." }, { "href": "https://www.ncbi.nlm.nih.gov/pubmed/9214531", "text": "Mayo-Smith MF. Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal. JAMA. 1997 Jul 9;278(2):144-51." }, { "href": "https://accessmedicine.mhmedical.com/content.aspx?bookid=1130&sectionid=79757307", "text": "Schuckit M. Alcohol and alcoholism. In: Brunwald E, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL. Harrison’s Principles of Internal Medicine.Vol. 2. 15th ed. New York, NY: McGraw-Hill Professional Publishing; 2001:2561–2566." }, { "href": "https://www.ncbi.nlm.nih.gov/pubmed/?term=11444401", "text": "Jaeger TM, Lohr RH, Pankratz VS. Symptom-triggered therapy for alcohol withdrawal syndrome in medical inpatients. Mayo Clin Proc 2001; 76:695." }, { "href": "https://www.ncbi.nlm.nih.gov/pubmed/?term=12020181", "text": "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; 162:1117. " }, { "href": "https://pubmed.ncbi.nlm.nih.gov/15119493/", "text": "Nuss MA, Elnicki DM, Dunsworth TS, Makela EH. Utilizing CIWA-Ar to assess use of benzodiazepines in patients vulnerable to alcohol withdrawal syndrome. W V Med J. 2004 Jan-Feb;100(1):21-5." }, { "href": "https://www.ncbi.nlm.nih.gov/pubmed/16912820", "text": "Roffman JL, Stern TA. Alcohol Withdrawal in the Setting of Elevated Blood Alcohol Levels. Primary Care Companion to The Journal of Clinical Psychiatry. 2006;8(3):170-173." }, { "href": "https://www.ncbi.nlm.nih.gov/pubmed/?term=22479099", "text": "Ng K, Dahri K, Chow I, Legal M. Evaluation of an alcohol withdrawal protocol and a preprinted order set at a tertiary care hospital. Can J Hosp Pharm. 2011 Nov;64(6):436-45." } ], "Outcomes": [], "Validation": [ { "href": "https://www.ncbi.nlm.nih.gov/pubmed/10934575", "text": "Reoux JP, Miller K. Routine hospital alcohol detoxification practice compared to symptom triggered management with an Objective Withdrawal Scale (CIWA-Ar). Am J Addict. 2000;9:135–44. PubMed PMID: 10934575." } ], "Validations": [] }

pearls

• The Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) scale has ten items, each evaluated independently then aggregated to yield a score correlating with severity of alcohol withdrawal.
• There is no absolute relationship between alcohol use pattern and risk of physiologic dependence or withdrawal for a given individual. In general, any suspicion of daily alcohol use over several weeks or more, regardless of quantity, should raise concern for potential alcohol withdrawal.
• Cannot be used effectively in intubated/sedated patients. A sedation scale such as the Richmond Agitation-Sedation Scale (RASS) is more appropriate in this setting.
• Additional variables that may contribute to risk include age, medical comorbidities like hepatic dysfunction, concomitant medication use, and low seizure threshold (Roffman JL 2006).

usecase

Patients in a variety of settings, including outpatient, emergency, psychiatric, and general medical-surgical units, for whom there is clinical concern for alcohol withdrawal.

reasons

The CIWA-Ar provides an efficient (<5 mins) and objective means of assessing alcohol withdrawal that can then be utilized in treatment protocols. Patients frequently under-report alcohol use and physicians often overlook alcohol problems in patients (Kitchens JM 1994). It is estimated that 1 of every 5 patients admitted to a hospital abuses alcohol (Schuckit 2001). Unrecognized alcohol withdrawal can lead to potentially life-threatening consequences including seizures and delirium tremens.

next_advice

• Benzodiazepines are generally used to control psychomotor agitation and prevent progression to more severe withdrawal.
• DiazePAM (Valium), LORazepam (Ativan), and chlordiazePOXIDE (Librium) are the most frequently used benzodiazepines. Follow your hospital's own alcohol withdrawal protocol; frequently treatment begins with benzodiazepines when CIWA-Ar scores reach 8-10, with standing or as needed dosing for scores 10-20. Some protocols even include transfer to the ICU for scores >20.
• Consider additional supportive care, including intravenous fluids, nutritional supplementation, and frequent clinical reassessment including vital signs.

next_actions

Other conditions can mimic or coexist with alcohol withdrawal, including:

• Drug overdose.
• Trauma (eg, intracranial hemorrhage).
• Infection (eg, meningitis).
• Metabolic derangements.
• Hepatic failure.
• Gastrointestinal bleeding.

Consider additional testing to rule out alternative diagnoses, especially if presentation includes altered mental status and/or fever.

next_management

Assessment protocols utilizing CIWA-Ar vary and include medication dosing triggered by symptoms only and combined symptom-triggered + fixed-dose medication dosing.

diseases

[ "Drug/Alcohol Use", " Drug/Alcohol Use" ]

instructions

published

2022-04-21T20:28:59.683Z

purpose

[ "Prognosis" ]

search_terms

[ "etoh", "withdrawl", "seizure", "alcohol", "booze", "liquor", "beer" ]

seo

{ "keywords_en": "alcohol withdrawal severity, etoh seizure severity, CIWA, withdrawal severity, etoh withdrawal score, withdrawal symptoms score, alcoholism severity, alcoholism severuty score, withdrawal etoh score, withdrawal etoh calc, etoh ciwa, ciwa calc, ciwa score, ciwa mdcalc, ciwa-ar calc, cwa-ar, ciwa-ar score, withdrawal severity, withdrawal severity score, withdrawal alcohol score, withdrawal alcohol severity, withdrawal alcoholics, ciwa alcoholics, ciwa alcoholism, objectify alcohol sx, objectify alcoholic sx, objectify withdrawal, objectify withdrawal sx, objectify withdrawal alcohol, objectify withdrawal etoh, objectify withdrawal alc, objectify w/d sx, objectify w/d, objectify w/d symptoms, objectify w/d sx, objectify w/d etoh, objectify w/d alc sx, withdrawal ar, withdrawal symptom severity, sx severity alc withdrawal, sx severity etoh withdrawal", "meta_description_en": "The CIWA-Ar for Alcohol Withdrawal objectifies severity of alcohol withdrawal symptoms." }

specialty

[ "Anesthesiology", "Emergency Medicine", "Family Practice", "Internal Medicine", "Psychiatry" ]

departments

[ "Neurologic" ]

tags

[]

version_number

1

versions

[]

related

[ { "calcId": 10446, "short_title_en": "BAWS", "slug": "brief-alcohol-withdrawal-scale-baws" }, { "calcId": 10527, "short_title_en": "CRAFFT", "slug": "car-relax-alone-forget-friends-trouble-crafft-questionnaire" }, { "calcId": 10525, "short_title_en": "BAM", "slug": "brief-addiction-monitor-bam" } ]

ismed

true

section

[ "whenToUseViewed", "pearlsPitfallsViewed", "whyUseViewed", "nextStepsViewed", "evidenceViewed" ]

cleaned_departments

[ "neurology" ]

cleaned_use

[ "Patients in a variety of settings, including outpatient, emergency, psychiatric, and general medical-surgical units, for whom there is clinical concern for alcohol withdrawal." ]

pub

true