What is the CIWA-Ar score?

The CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol, revised) is a 10-item scale that quantifies the severity of alcohol withdrawal syndrome. Items include nausea/vomiting, tremor, paroxysmal sweats, anxiety, agitation, tactile/auditory/visual disturbances, headache, and orientation. Maximum score is 67.

How is the CIWA-Ar score interpreted?

Scores 18: Severe withdrawal, high risk for seizures and delirium tremens — aggressive benzodiazepine dosing required. Scores > 20 warrant ICU-level monitoring.

How often should CIWA-Ar be assessed?

In symptom-triggered therapy protocols, CIWA-Ar is assessed every 1–2 hours. Benzodiazepines are administered when score ≥ 10 (or ≥ 8 per some protocols). Once scores are < 10 for 24 hours, monitoring frequency can decrease. Symptom-triggered protocols use less medication and have shorter treatment durations than fixed-dose regimens.

What are the limitations of the CIWA-Ar?

CIWA-Ar requires cooperative, communicative patients and cannot be used in intubated, sedated, or encephalopathic patients. It is subjective and requires trained assessors. The MINDS (Minnesota Detoxification Scale) or PAWSS may be alternatives in specific populations.

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CIWA-Ar Score (Alcohol Withdrawal)

Assess severity of alcohol withdrawal using the revised Clinical Institute Withdrawal Assessment scale. Score range: 0–67. Guides symptom-triggered benzodiazepine therapy.

Assessment Items

Nausea/Vomiting

Tremor (arms extended, fingers spread)

Paroxysmal Sweats

Anxiety

Agitation

Tactile Disturbances

Auditory Disturbances

Visual Disturbances

Headache, Fullness in Head

Orientation & Clouding

CIWA-Ar Score (max 67)

Minimal withdrawal

≤ 8Minimal withdrawal — monitor, no benzos needed

9–15Mild withdrawal — consider PRN benzos

16–20Moderate withdrawal — treat with scheduled/PRN benzos

> 20Severe withdrawal — aggressive treatment, ICU consideration

Disclaimer: For educational purposes only. Not a substitute for clinical judgment.

When to use

Use CIWA-Ar to monitor and guide symptom-triggered benzodiazepine therapy in patients at risk for or experiencing alcohol withdrawal. Assess every 1–4 hours depending on severity.

Clinical pearls

Symptom-triggered therapy (CIWA-based dosing) reduces total benzodiazepine use and ICU admissions compared to fixed-schedule dosing.
CIWA-Ar is unreliable in intubated, obtunded, or patients with severe cognitive impairment — use clinical assessment instead.
Alcohol withdrawal seizures can occur as early as 6 hours after last drink; delirium tremens typically at 48–72 hours.
Phenobarbital is increasingly used as an adjunct or alternative in severe/refractory withdrawal.

References

Sullivan JT, et al. Assessment of alcohol withdrawal: the revised CIWA scale (CIWA-Ar). Br J Addict. 1989;84(11):1353-1357.
Saitz R, et al. Individualized treatment for alcohol withdrawal: a randomized double-blind controlled trial. JAMA. 1994;272(7):519-523.

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About This Tool

What Is the CIWA-Ar?

The Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) is a 10-item clinical scale developed by Sullivan et al. in 1989 to quantify the severity of alcohol withdrawal syndrome. It takes approximately 5 minutes to administer and assesses nausea/vomiting, tremor, sweating, anxiety, agitation, tactile/auditory/visual disturbances, headache, and orientation. The maximum score is 67.

Symptom-Triggered Therapy

The CIWA-Ar enables symptom-triggered benzodiazepine dosing, which has been shown to be superior to fixed-schedule dosing. Patients are assessed every 1–4 hours; benzodiazepines are administered when the CIWA-Ar score exceeds a threshold (typically 8–10). This approach reduces total benzodiazepine exposure by 60% and shortens treatment duration by 50% compared to fixed-schedule protocols (Saitz et al., JAMA 1994).

🔑 Clinical Pearls

CIWA-Ar > 20: severe withdrawal — consider lorazepam 2 mg IV q15-30 min until CIWA < 10, or phenobarbital.
The timeline: tremor/anxiety (6-24h) → seizures (12-48h) → delirium tremens (48-72h).
Patients who've had prior withdrawal seizures or DTs should receive prophylactic benzodiazepines regardless of CIWA score.
Thiamine 500 mg IV × 3 days should be given before or with glucose to prevent Wernicke encephalopathy.

Key References

Sullivan JT, et al. Assessment of alcohol withdrawal: the revised CIWA scale. Br J Addict. 1989;84(11):1353-1357.
Saitz R, et al. Individualized treatment for alcohol withdrawal. JAMA. 1994;272(7):519-523.
Mayo-Smith MF. Pharmacological management of alcohol withdrawal. JAMA. 1997;278(2):144-151.

Formula last verified: February 2026