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Three Part Question

In [Adult patients with withdrawal symptoms] is [the CIWA score effective in guiding pharmacotherapy] to [manage symptoms]?

Clinical Scenario

A patient in the emergency department shows the beginning of alcohol withdrawal symptoms. You know that you can start them on a standard tapering course of treatment but have been told by a colleague that symptom based treatment using the patients CIWA score would be better

Search Strategy

Using OVID interface;
Medline 1996 to June week 3 2007:
[ciwa.mp] AND [exp Alcohol Withdrawal Seizures or withdrawal.mp. or exp Alcohol Withdrawal Delirium or exp Substance Withdrawal Syndrome]
Embase 1996 - 2007 week 27
[ciwa.mp] AND [exp Alcohol Withdrawal Seizures or withdrawal.mp. or exp Alcohol Withdrawal Delirium or exp Substance Withdrawal Syndrome]

Search Outcome

Medline found 40 papers, Embase found 40 papers. Cochrane found 3 papers. 5 papers were relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Reoux JP and Miller K 2000 USA	172 patients admitted over a consecutive 8 month period were selected based on ICD-9 codes of these 40 met inclusion criteria. 26 received symptom based therapy and 14 received standard treatment.	Retrospective Study	Dosage received Symptom based vs Standard	4.5 +/- 4.2 vs 12.7 +/- 6.5 p=0.007	Lack of randomisation. Symptom based patients treated on specialist ward.
			Amount received Symptom based vs Standard	225.0 +/- 210.4 mg vs 547.5 +/- 342.9mg P=0.034
			Duration Symptom based vs Standard	25.3 +/- 24.7hr vs 85.7 +/- 57.7 hr p= 0.011
Nuss MA et al 2004 USA	16 patients identified as alcohol dependent or with a positive blood alcohol level on admission. Patients were given benzodiazepines if there CIWA-Ar was greater or equal to 10.	Prospective	Patients safe detoxification	the 9 patients not given benzodiazepines due to CIWA-Ar all finished detoxification safely	The mean CIWA-Ar score of the CIWA score < 10 group was 3.8 +/- 2.4. Therefore the actual highest CIWA score for which benzodiazepines were not given was only 6 or 7.
Weaver MF et al 2006 USA	183 subjects, Symptom triggered group received lorazepam based on CIWA-Ar score. Fixed schedule group received scheduled lorazepam with tapering over 4 days.	Comparative Study, RCT	Amount of lorazepam administered	Symptom triggered patients received less lorazepam.
Silpakit C et al 1999 Thailand	62 cases of Alcohol withdrawal admitted to a psychiatric hospital. One group received chlordiazepoxide based on symptoms. The other group received fixed scheduled treatment.	Comparative Study	Amount of chlordiazepoxide administered	The group with symptom based therapy received less chlordiazepoxide	Small study number
Thaller V et al 1999 Croatia	39 alcoholics with withdrawal symptoms and 39 alcoholics without withdrawal symptoms. All aged 20-65 years old.	Comparative Study	sensitivity of tests in predicting alcoholism and alcohol withdrawal	60% sensitivity was shown for MCV-E, gamma-GT and CTD in both alcoholics with withdrawal symptoms and without	small sample number. lack of control sample

Comment(s)

The use of symptom based treatment with The CIWA-Ar score appears to be effective at controlling withdrawal symptoms and reducing the amount of treatment administered

Clinical Bottom Line

The CIWA-Ar score should be used as a symptom based guide to the pharmacotherapy of patients suffering from alcohol withdrawal

References

1. Reoux JP and Miller K Routine Hospital Alcohol Detoxification Practice Compared To Symptom Driven Management with an Objective Withdrawal Scale (CIWA-Ar) American journal of addictions 2000 9:2 135-144
2. Nuss MA et al Utilizing CIWA-Ar to assess use of benzodiazepines in patients vulnerable to alcohol withdrawal syndrome. West Virginia Medical Journal. 2004 Jan-Feb, 100(1):21-5
3. Weaver MF et al Alcohol withdrawal pharmacotherapy for inpatients with medical comorbidity. Journal of Addictive Diseases. 2006; 25(2):17-24
4. Silpakit C et al Treatment of alcohol withdrawal: A fixed schedule regimen versus symptom-triggered regimen. International Medical Journal 1999, Vol. 6(4)(pp 287-289).
5. Thaller V et al Biochemical tests in the diagnosis of alcoholism (The correlation of the sensitivity of the conventional tests for the diagnosis of alcoholism and alcohol withdrawal syndrome). European Journal of Psychiatry 1999, Vol. 13(2)(pp 107-119).