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Three Part Question

In [adults thought to be withdrawing from alcohol] is [the CIWA-Ar score better then clinical judgement] at [assessing the severity of withdrawal]?

Clinical Scenario

A patient is showing signs of alcohol withdrawal. You want to know whether using the CIWA-Ar tool is better than using your own clinical judgement at assessing whether this patient is indeed in alcohol withdrawal and preventing symptoms.

Search Strategy

Ovid interface.
Medline 1948 to week 2 June 2011
{[exp.ethanol OR alcohol$.mp] AND [substance withdrawal syndrome.mp OR exp.substance withdrawal syndrome] OR [ex.alcohol withdrawal seizures OR aclohol withdrawal delerium OR alcoholic neuropathy] AND [CIWA.mp OR CIWA-Ar.mp OR clinical institute withdrawal assessment.mp]}LIMIT to English language AND human.
Embase 1980 to 2011 week 23
{[exp.alcohol withdrawal OR exp.delirium tremens] AND [CIWA.mp OR CIWA-Ar.mp OR clinical institute withdrawal assessment.mp]}LIMIT to English language and human.
Psych info. 1806 to June Week 1 2011
{[exp.alcohol withdrawal OR exp.delirium tremens] AND [CIWA.mp OR CIWA-Ar.mp OR clinical institute withdrawal assessment.mp]}LIMIT to English language and human.
CINAHL 1994-2011
[alcohol withdrawal] AND [CIWA OR clinical institute withdrawal assessment]

Search Outcome

Medline found 86 articles, Embase found 92 articles, Psych Info. found 74 articles and CINAHL found 23 articles. Of these, 4 articles were found to be relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Foy A et.al. 1988 Australia	203 patients admitted to any speciality, aged between 20 and 75 who were identified at risk of alcohol withdrawal within the first 24 hours. Risk was defined as 1. Intake of 100g or more of alcohol every day for 10 years. 2. Previously documented treatment for alcohol withdrawal 3. Documented current alcohol related problems. Excluded if had fit within the first 24 hours.	Comparative study.	Occurrence of severe alcohol withdrawal symptoms (AWS)	110 patients scored above 15. 75 received diazepam of which 11 developed severe AWS. 35 were not treated of which 21 developed AWS.	No comparison to a control group assessed without the CIWA-Ar score.
			Relative risk of developing severe AWS depending on CIWA score.	<15=1.92, 16-20=2.74, 21-25=5.46, >25=7.50.
Sullivan JT. et.al. 1991 USA	133 patients assessed with CIWA score, 117 treated without a score over a 2 year period, all with a primary diagnosis of alcohol dependence.	Retrospective cohort study.	Drug requirements: CIWA scored vs. non CIWA scored.	Median dose: CIWA 50mg vs. non-CIWA75mg.	Non-blinded. No randomisation, group allocation at doctor's digression. No size estimates performed.
			Length of hospital stay (days)	CIWA 33.9+/-2.2 vs. non- CIWA 4.3+/-2.4
			Complication rates.	No. of seizures: CIWA;1 vs. non-CIWA;0
Reoux JP et.al. 2000 USA	40 patients admitted over an 8 month period based on ICD-9 code. Exclusion criteria- severe liver disease, primary diagnosis other than alcohol withdrawal, opiate dependent. Patients medicated either depending on the CIWA score, clinical judgement (PRN) or standard set treatment.	Retrospective cohort study.	No. of doses of medication recieved CIWA vs non-CIWA	1.7+/- 3.1 vs. 10.4+/- 7.9	Small sample size. No blinding. Male dominance.
			No. of doses of medication recieved CIWA vs. PRN	1.7+/- 3.1 vs. 4.8+/- 8.6
			mg of medication received CIWA vs non-CIWA	82.7+/-153.6 vs. 367.5+/- 98.2
			mg of medication received CIWA vs. PRN	82.7+/- 153.6 vs. 204.2+/- 382.9
			Duration of medication use (hours)CIWA vs non-CIWA	10.7+/- 20.7 vs. 64.3+/- 60.4
			Duration of medication use (hours)CIWA vs. PRN	10.7+/- 20.7 vs. 40.2+/-75.4
			Adverse events.	Non in either group.
Hecksel KA 2008 USA	124 randomly selected patients over a 12 month period who were receiving symptom triggered therapy based on the CIWA-Ar screening tool for alcohol withdrawal.	Randomized prospective cohort study.	To determine whether patients were placed appropriately on STT according to inclusion criteria of being able to communicate verbally and recent alcohol use.	60 (48%) met both inclusion criteria.
				9 (8%) could not communicate verbally.
				35 (28%) had not been drinking.
				20 (16%) did not meet either criteria.

Comment(s)

Care must be taken in patients who are sicker as their symptoms were found to be more unpredictable. Patients should also be asked about alcohol consumtion by either using another tool to assess alcohol intake or simply an alcohol history to confirm that they are at risk of alcohol withdrawal.

Clinical Bottom Line

CIWA-Ar is a useful tool to use in the A+E department to assess whether a patient is in alcohol withdrawal and if they need medication.

References

1. Foy, A; March, S; Drinkwater, V. Use of an objective clinical scale in the assessment and management of alcohol withdrawal in a large general hospital. Alcoholism, Clinical and Experimental Research. 1988; Jun;12(3):360-4
2. Sullivan, JT; Swift, RM; Lewis, DT. (1991). Benzodiazepine requirements during alcohol withdrawal syndrome: clinical implications of using a standardized withdrawal scale. Journal of Clinical Psychopharmacology 1991 Oct;11(5):291-5.
3. Reoux, Joseph P; Miller, Kristin Routine Hospital Alcohol Detoxification Practice Compared to Symptom Triggered Management with an Objective Withdrawal Scale (CIWA-Ar). The American Journal on Addictions 2000; 9:135-144.
4. Hecksel, KA; Bostwick, JM; Jaeger, TM; Cha SS. Inappropriate use of symptom-triggered therapy for alcohol withdrawal in the general hospital. Mayo Clinical Proceedings. 2008 Mar;83(3):274-9.