Home › Calculators › CIWA-Ar
Calculator · Alcohol withdrawal severity
CIWA-Ar
Ten domains scored on the Clinical Institute Withdrawal Assessment for Alcohol, revised. Used to drive symptom-triggered benzodiazepine dosing and to decide monitoring frequency. Maximum score 67.
What it asks
| Criterion | Points |
|---|---|
| Nausea and vomiting | None — 0 Mild nausea, no vomiting — 1 Intermittent nausea with dry heaves — 4 Constant nausea, frequent dry heaves and vomiting — 7 |
| Tremor | No tremor — 0 Not visible but felt fingertip to fingertip — 1 Moderate, with arms extended — 4 Severe, even with arms not extended — 7 |
| Paroxysmal sweats | None visible — 0 Barely perceptible, palms moist — 1 Beads of sweat obvious on forehead — 4 Drenching sweats — 7 |
| Anxiety | At ease — 0 Mildly anxious — 1 Moderately anxious or guarded — 4 Equivalent to acute panic — 7 |
| Agitation | Normal activity — 0 Somewhat more than normal — 1 Moderately fidgety and restless — 4 Paces or constantly thrashes about — 7 |
| Tactile disturbance Itching, pins and needles, burning, numbness, or a sensation of insects on the skin. | None — 0 Very mild — 1 Moderate — 4 Continuous hallucinations — 7 |
| Auditory disturbance | Not present — 0 Very mild harshness or ability to frighten — 1 Moderate hallucinations — 4 Continuous hallucinations — 7 |
| Visual disturbance | Not present — 0 Very mild sensitivity — 1 Moderate hallucinations — 4 Continuous hallucinations — 7 |
| Headache or fullness in head Do not rate dizziness or light-headedness here. | Not present — 0 Mild — 1 Moderate to severe — 4 Extremely severe — 7 |
| Orientation and clouding of sensorium | Orientated, can do serial additions — 0 Cannot do serial additions, or uncertain about date — 1 Disorientated for date by no more than 2 calendar days — 2 Disorientated for date by more than 2 calendar days — 3 Disorientated for place and/or person — 4 |
How to read the score
| Score | Means | What to do |
|---|---|---|
| 0–9 | Absent or minimal withdrawal | Medication not usually required. Continue monitoring and give thiamine (Pabrinex) — do not omit it. |
| 10–19 | Mild to moderate withdrawal | Symptom-triggered benzodiazepine per local protocol. Reassess after each dose. Continue parenteral thiamine. |
| 20–67 | Severe withdrawal | High risk of seizures and delirium tremens. Escalate, treat promptly and consider a higher level of care. Ensure adequate parenteral thiamine before any glucose. |
Before you use it
CIWA-Ar is unreliable if the patient cannot communicate — intubated, obtunded or a significant language barrier. Never withhold thiamine while waiting on a score. Published severity thresholds vary between trusts — check yours.
Source: Sullivan et al, Br J Addiction 1989 / NICE CG100
Checked, and shown
Every threshold on this page was checked against its primary source by a practising doctor. Here is what that involved, and what it found.