CIWA-Ar alcohol withdrawal scale

What goes into the CIWA-Ar

• Nausea and vomiting (0–7): None (0); 1 (1); 2 (2); 3 (3); 4 (4); 5 (5); 6 (6); Most severe (7)
• Tremor (0–7): None (0); 1 (1); 2 (2); 3 (3); 4 (4); 5 (5); 6 (6); Most severe (7)
• Paroxysmal sweats (0–7): None (0); 1 (1); 2 (2); 3 (3); 4 (4); 5 (5); 6 (6); Most severe (7)
• Anxiety (0–7): None (0); 1 (1); 2 (2); 3 (3); 4 (4); 5 (5); 6 (6); Most severe (7)
• Agitation (0–7): None (0); 1 (1); 2 (2); 3 (3); 4 (4); 5 (5); 6 (6); Most severe (7)
• Tactile disturbances (0–7): None (0); 1 (1); 2 (2); 3 (3); 4 (4); 5 (5); 6 (6); Most severe (7)
• Auditory disturbances (0–7): None (0); 1 (1); 2 (2); 3 (3); 4 (4); 5 (5); 6 (6); Most severe (7)
• Visual disturbances (0–7): None (0); 1 (1); 2 (2); 3 (3); 4 (4); 5 (5); 6 (6); Most severe (7)
• Headache or fullness in head (0–7): None (0); 1 (1); 2 (2); 3 (3); 4 (4); 5 (5); 6 (6); Most severe (7)
• Orientation (0–4): Oriented (0); Unsure of date (1); Date off by ≤ 2 days (2); Date off by > 2 days (3); Disoriented to place or person (4)

How to interpret the result

• < 10: minimal withdrawal; usually no medication
• 10–18: moderate withdrawal; symptom-triggered treatment
• > 18: severe withdrawal; high risk of seizures and delirium tremens

Clinical pearls

• Symptom-triggered dosing uses less medication than fixed schedules in patients who can communicate.
• CIWA-Ar needs a communicative patient; it is not valid in delirium, intubation or severe illness.
• The 2020 ASAM alcohol withdrawal guideline supports benzodiazepines first-line, with phenobarbital as an alternative.

Evidence

1. Sullivan JT, et al. Assessment of alcohol withdrawal: the revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). Br J Addict. 1989;84:1353-1357.

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