Using The CIWA score to guide Alcohol Withdrawal Management
Date First Published:
June 28, 2007
Last Updated:
July 9, 2007
Report by:
Neal Larkman, Medical Student (Manchester Royal Infirmary)
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;
Search Details:
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]
[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]
Outcome:
Medline found 40 papers, Embase found 40 papers. Cochrane found 3 papers. 5 papers were relevant
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Routine Hospital Alcohol Detoxification Practice Compared To Symptom Driven Management with an Objective Withdrawal Scale (CIWA-Ar) 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 | ||||
| Utilizing CIWA-Ar to assess use of benzodiazepines in patients vulnerable to alcohol withdrawal syndrome. 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. |
| Alcohol withdrawal pharmacotherapy for inpatients with medical comorbidity. 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. | |
| Treatment of alcohol withdrawal: A fixed schedule regimen versus symptom-triggered regimen. 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 |
| 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). 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 |
Author Commentary:
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
Bottom Line:
The CIWA-Ar score should be used as a symptom based guide to the pharmacotherapy of patients suffering from alcohol withdrawal
References:
- Reoux JP and Miller K. Routine Hospital Alcohol Detoxification Practice Compared To Symptom Driven Management with an Objective Withdrawal Scale (CIWA-Ar)
- Nuss MA et al. Utilizing CIWA-Ar to assess use of benzodiazepines in patients vulnerable to alcohol withdrawal syndrome.
- Weaver MF et al. Alcohol withdrawal pharmacotherapy for inpatients with medical comorbidity.
- Silpakit C et al. Treatment of alcohol withdrawal: A fixed schedule regimen versus symptom-triggered regimen.
- 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).