Alcohol Withdrawal Risk
Patient with heavy alcohol use stopping/reducing
All Pathways
Internal MedicineManagement
Alcohol Withdrawal Syndrome Management (CIWA-Ar)
Alcohol Withdrawal Syndrome Management (CIWA-Ar): Alcohol Withdrawal Risk → Risk Assessment → CIWA-Ar Assessment → CIWA-Ar Score Interpretation → Minima...
Pathway Overview
14 steps
Algorithm Steps
14 total
01Start 02Action Risk Assessment
Identify high-risk patients
- History of withdrawal seizures or DT
- Daily heavy drinking >10 years
- Prior complicated withdrawals
- Concurrent illness/surgery
- Age >65
03Action CIWA-Ar Assessment
Score 0-67 based on 10 items
- Nausea/vomiting (0-7)
- Tremor (0-7)
- Sweating (0-7)
- Anxiety (0-7)
- Agitation (0-7)
- Tactile disturbances (0-7)
- Auditory disturbances (0-7)
- Visual disturbances (0-7)
- Headache (0-7)
- Orientation/clouding (0-4)
04Decision CIWA-Ar Score Interpretation
Guides treatment intensity
- 0-8: Minimal withdrawal
- 9-15: Mild withdrawal
- 16-20: Moderate withdrawal
- >20: Severe withdrawal
05Action Minimal (CIWA 0-8)
Supportive care, monitoring
- No pharmacotherapy needed
- Supportive care
- Reassess CIWA q4-8h
- Thiamine 100mg daily
06Action Supportive Measures (All Patients)
Essential adjuncts
- Thiamine 100mg IV/IM x3 days before glucose
- Folate 1mg daily
- Electrolyte repletion (Mg, K, Phos)
- IV fluids if dehydrated
- Quiet, well-lit environment
- Fall precautions
07Action Monitoring
Frequency based on severity
- CIWA q1h during active treatment
- CIWA q4h once stable
- Vitals q2-4h
- Watch for aspiration if sedated
08Outcome Disposition Planning
After withdrawal managed
- Addiction medicine/psychiatry consult
- Consider naltrexone, acamprosate
- Outpatient treatment referral
- Social work involvement
09Action Mild (CIWA 9-15)
Consider PRN benzos
- May observe without medication
- Or PRN benzos if high risk
- Reassess CIWA q2-4h
- Thiamine + multivitamin
- Path rejoins step 06Shared downstream outcome
10Action Moderate (CIWA 16-20)
Symptom-triggered benzos
- Lorazepam 2-4mg or Diazepam 10-20mg
- Repeat q1h until CIWA <10
- CIWA q1-2h during active treatment
- Thiamine 100mg IV before glucose
11Action Benzodiazepine Options
Choose based on patient factors
- Lorazepam: 2-4mg PO/IV q1h PRN (liver disease, elderly)
- Diazepam: 10-20mg PO/IV q1h PRN (active metabolite, longer)
- Chlordiazepoxide: 50-100mg q6h (oral, outpatient)
- Symptom-triggered > fixed-dose in most cases
- Path rejoins step 06Shared downstream outcome
12Action Severe (CIWA >20)
Aggressive treatment required
- Higher/more frequent benzo doses
- Consider ICU monitoring
- May need phenobarbital adjunct
- Watch for respiratory depression
- Path rejoins step 11Shared downstream outcome
13Warning ⚠️ Delirium Tremens (DT)
Medical emergency - mortality 5-15% untreated
- Onset 48-72h after last drink
- Confusion, hallucinations, autonomic instability
- ICU admission recommended
- High-dose IV benzos
- Consider propofol/dexmedetomidine if refractory
14Warning ⚠️ Withdrawal Seizures
Peak 12-48h after last drink
- Usually generalized tonic-clonic
- Treat with IV benzo (lorazepam 4mg)
- May herald DT development
- Not typically chronic epilepsy
Guideline Source
ASAM Clinical Practice Guideline on Alcohol Withdrawal Management
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- CIWA requires patient cooperation (may not be usable if intubated/obtunded)
- Does not replace clinical judgment
- Concurrent medical conditions may affect presentation
- Drug dosing should follow institutional protocols
- Delirium tremens is medical emergency
Applicable Regions
USEUGlobal
Global: CIWA-Ar widely adopted internationally
Version 1Next review: 2027-01-11
Next steps
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Related Resources
Frequently Asked Questions
What is the Alcohol Withdrawal Syndrome Management (CIWA-Ar)?
The Alcohol Withdrawal Syndrome Management (CIWA-Ar) is a management clinical algorithm for Internal Medicine. It provides a structured decision tree to guide clinical decision-making, based on ASAM Clinical Practice Guideline on Alcohol Withdrawal Management.
What guideline is the Alcohol Withdrawal Syndrome Management (CIWA-Ar) based on?
This algorithm is based on ASAM Clinical Practice Guideline on Alcohol Withdrawal Management (DOI: 10.1097/ADM.0000000000000573).
What are the limitations of the Alcohol Withdrawal Syndrome Management (CIWA-Ar)?
Known limitations include: CIWA requires patient cooperation (may not be usable if intubated/obtunded); Does not replace clinical judgment; Concurrent medical conditions may affect presentation; Drug dosing should follow institutional protocols; Delirium tremens is medical emergency. Individual patient factors may require deviation from these recommendations.
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