Alcohol Withdrawal in the Inpatient Setting

Kylie Lucas, PharmD, BCPS; Glenn R. Grantner, PharmD, BCPS; Jonathan Street, PharmD


US Pharmacist. 2019;44(11):HS-8-HS12. 

In This Article

Diagnosis and Screening

Initial evaluation of a patient with AWS relies heavily on clinical presentation. Diagnosis is based mainly on symptoms and may be guided by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). DSM-5 criteria for AWS include presentation with any two identified symptoms, including autonomic symptoms (diaphoresis, tachycardia), increased hand tremors, nausea and/or vomiting, psychomotor agitation, anxiety, generalized tonic-clonic seizures, and hallucinations.[2,12]

Obtaining a medical and social history is also necessary for diagnosis and to rule out other concurrent conditions with presentations similar to AWS. Historical data including quantity of alcohol ingested, duration of alcohol use, time since last drink, history of alcohol withdrawal, abuse of other agents, and concurrent medical or psychological problems can provide important context for individual patient cases. Laboratory data such as metabolic panels, blood-alcohol levels, liver-function tests, and toxicology screens may be useful, especially when the provider is unable to obtain an adequate patient history.[6,13–15]

Although several assessment tools are available to aid in diagnosis, the Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar), is the most commonly used tool.[16–18] CIWA-Ar, a 10-item survey that measures the severity of alcohol withdrawal, requires minimal patient participation. Symptoms assessed include nausea and vomiting; tremor; paroxysmal sweats; anxiety; agitation; tactile, auditory, and visual disturbances; headache or fullness in head; and orientation and clouding of sensorium. Most items are rated on a scale of 0 to 7, with 0 being normal and 7 being extremely severe. The cumulative score, which can be a maximum of 67, corresponds to the severity of the patient's withdrawal. A cumulative score of 1 to 7 indicates mild withdrawal, 8 to 15 denotes moderate withdrawal, and 16 or higher means severe withdrawal.[16–19] Institutions frequently use CIWA-Ar in standardized protocols in order to help treat AWS.