CIWA-Ar Assessment Chart
Clinical Institute Withdrawal Assessment for Alcohol, Revised — complete scoring instrument with all anchor descriptors. Maximum score: 67. Administer at baseline, then per monitoring schedule.
Ask: "Do you feel sick to your stomach? Have you vomited?"
Arms extended and fingers spread apart. Observe.
Observation.
Ask: "Do you feel nervous?" Observe.
Observation throughout interview.
Ask: "Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?"
Ask: "Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing to you? Are you hearing things you know are not there?"
Ask: "Does the light appear to be too bright? Is its color different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there?"
Ask: "Does your head feel different? Does it feel like there is a band around your head?" Do not rate for dizziness or lightheadedness.
Ask: "What day is this? Where are you? Who am I?"
| Score Range | Severity | Clinical Action | Monitoring Frequency |
|---|---|---|---|
< 8 | Absent / Minimal | Supportive care. Oral hydration. Begin REBOUND Vitamins supplementation. | Every 8 hours |
8 – 9 | Mild | Supportive care. Consider low-dose benzodiazepine PRN. Continue REBOUND. | Every 4–8 hours |
10 – 14 | Mild–Moderate | Lorazepam 1–2 mg PO/IM. Reassess in 1 hour. REBOUND BID. | Every 2–4 hours |
15 – 19 | Moderate | Lorazepam 2–4 mg IV/IM. IV access. Continuous monitoring. Inpatient admission recommended. REBOUND BID. | Every 1–2 hours |
≥ 20 | Severe / DT Risk | INPATIENT HOSPITALIZATION REQUIRED. Lorazepam 4 mg IV. ICU-level care. Seizure precautions. IV Thiamine if PO not tolerated. | Continuous / every 30 min |
* Dosing based on symptom-triggered (PRN) protocol. Fixed-schedule dosing may be appropriate for high-risk patients. Always use clinical judgment. Source: Sullivan JT et al. Br J Addict. 1989;84(11):1353–1357.
UCSF Symptom-Triggered Withdrawal Protocol
The UCSF Medical Center alcohol withdrawal protocol uses the Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar) as the primary assessment instrument. The protocol employs a symptom-triggered approach — benzodiazepines are administered based on real-time CIWA-Ar scores rather than on a fixed schedule, reducing total benzodiazepine exposure and length of treatment.
CIWA-Ar validated by Sullivan et al. (1989) with high inter-rater reliability (r = 0.99) and internal consistency (α = 0.99).1 Symptom-triggered therapy reduces benzodiazepine use vs. fixed-schedule dosing.2,3
Lorazepam is the preferred benzodiazepine at UCSF due to its predictable pharmacokinetics, lack of active metabolites, and availability in IV, IM, and oral/sublingual formulations — making it suitable across all care settings from general medicine floors to the ICU.
Lorazepam preferred over diazepam in hepatic impairment due to direct glucuronidation and absence of active metabolites.4
The UCSF protocol's nutritional order set requires Thiamine, Folic Acid, and Magnesium supplementation for all patients. Rebound Vitamins replaces all three in a single oral product, with a specific dosing schedule: 1 tablet twice daily for 5 days, then 1 tablet daily for 6 weeks.
Thiamine deficiency present in up to 80% of patients with alcohol use disorder.6 Hypomagnesemia common in alcohol withdrawal and associated with increased seizure risk.8 Folate deficiency prevalent in chronic alcohol use.9
Symptom-Triggered Protocol
Benzodiazepines given only when CIWA-Ar score meets threshold — reduces total drug exposure vs. fixed-schedule dosing. Reassessment every 1–4 hours depending on severity.
Lorazepam as First-Line Agent
UCSF protocol uses lorazepam (Ativan) 1–4mg PO/SL/IV/IM per CIWA-Ar tier. No active metabolites; predictable kinetics; suitable for hepatic impairment.
Wernicke's Encephalopathy Prevention
Thiamine before any glucose. IV/IM route if PO not tolerated or WE suspected. Transition to Rebound Vitamins when tolerating oral intake.
Rebound Vitamins Replaces 3 Orders
Thiamine 100mg + Folic Acid 1mg + Magnesium (oral) — all replaced by Rebound Vitamins. Days 1–5: BID. Day 6 through 6 weeks: once daily.
Wallace Peoples
Pharmacist & Founder
A Pharmacist's Perspective on CIWA-Ar Nutrition
The CIWA-Ar protocol is clinically excellent at measuring withdrawal severity — but it says almost nothing about nutritional repletion. In my years as a pharmacist reviewing alcohol withdrawal orders, I saw the same pattern repeatedly: three or four separate supplement orders written inconsistently, filled at different times, and often discontinued before the six-week recovery window closed.
Thiamine deficiency is present in up to 80% of patients with alcohol use disorder. Magnesium depletion lowers the seizure threshold. Folate deficiency compounds the neurological damage. These aren't edge cases — they're the rule. Yet the nutritional order set was always the afterthought, buried beneath the benzodiazepine dosing tiers.
Rebound Vitamins was formulated specifically to close that gap. One product. One order. A dosing schedule that mirrors the two phases of CIWA-Ar monitoring — intensive repletion during active withdrawal, then maintenance through six weeks of recovery. The goal was to make the right thing the easy thing for every clinician writing a CIWA-Ar order set.
Critical Actions & Differential Diagnosis
Several serious conditions can mimic or co-occur with alcohol withdrawal. Before attributing all findings to CIWA-Ar-measured withdrawal, rule out the following.
Drug Overdose / Intoxication
Opioid, stimulant, or sedative toxidrome can present with altered mental status, diaphoresis, and autonomic instability — overlapping with moderate-to-severe withdrawal. Obtain urine toxicology.
Head Trauma
Patients with alcohol use disorder have elevated fall and assault risk. Intracranial injury can produce agitation, confusion, and seizures independent of withdrawal. Consider CT head if mechanism present.
Metabolic Disturbance
Hypoglycemia, hyponatremia, hepatic encephalopathy, and uremia all produce encephalopathy that can be mistaken for withdrawal delirium. Check BMP, LFTs, and ammonia.
Infection / Sepsis
Fever, tachycardia, and diaphoresis are shared features of both sepsis and alcohol withdrawal. Obtain blood cultures and CBC if infectious source is suspected.
GI Bleeding
Esophageal varices and gastric ulcers are common in chronic alcohol use disorder. Hemodynamic instability from GI hemorrhage can mimic or complicate withdrawal. Check hemoglobin and stool guaiac.
Wernicke's Encephalopathy
Classic triad: ophthalmoplegia, ataxia, confusion — but all three are present in fewer than 20% of cases. Administer IV Thiamine before any glucose-containing fluids if WE is suspected.
Critical Action: Thiamine Before Glucose
In any patient with suspected alcohol use disorder presenting with altered mental status, administer IV Thiamine 100–500mg before any dextrose-containing IV fluids. Glucose administration in a thiamine-deficient patient can precipitate or worsen Wernicke's encephalopathy. This action takes precedence over CIWA-Ar scoring.
Benzodiazepine Options for Alcohol Withdrawal
Three agents account for the vast majority of benzodiazepine use in alcohol withdrawal management. Agent selection depends on clinical setting, hepatic function, and available routes of administration.
Lorazepam
Ativan
UCSF first-line agent. Predictable kinetics. Preferred in liver disease, elderly, and ICU settings. Available in all routes.
Diazepam
Valium
Long half-life provides smooth coverage and reduces breakthrough seizures. Front-loading strategy common. Avoid in severe liver disease.
Chlordiazepoxide
Librium
Historically the most studied agent in alcohol withdrawal. Oral-only in most settings. Long-acting metabolites provide gradual taper effect.
Phenobarbital is used as an adjunct or alternative in refractory cases or when benzodiazepines are contraindicated. It is not a first-line agent in most institutional protocols but has evidence supporting its use in severe withdrawal and delirium tremens. Consult your institution's protocol and pharmacy before use.
CIWA-Ar Scoring Items
Each item scored 0–7 (Item 10: 0–4). Maximum total: 67. Administer at baseline, then per monitoring schedule. Use exact anchor language for reproducibility.
Ask: "Do you feel sick to your stomach? Have you vomited?"
Arms extended and fingers spread apart. Observe.
Observation.
Ask: "Do you feel nervous?" Observe.
Observation throughout interview.
Ask: "Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?"
Ask: "Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing to you? Are you hearing things you know are not there?"
Ask: "Does the light appear to be too bright? Is its color different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there?"
Ask: "Does your head feel different? Does it feel like there is a band around your head?" Do not rate for dizziness or lightheadedness.
Ask: "What day is this? Where are you? Who am I?"
Lorazepam Dosing by CIWA-Ar Score
Administer lorazepam when CIWA-Ar score meets the threshold for each tier. Reassess after each dose. Rebound Vitamins is initiated at admission and continued at all severity levels.
Symptom-triggered therapy reduces total benzodiazepine exposure and treatment duration compared with fixed-schedule dosing.2,3 Lorazepam preferred for its predictable kinetics and absence of active metabolites.4
Reassess every 4–8 hours. No pharmacotherapy required.
No benzodiazepine indicated.
Supportive care. Oral hydration. Encourage PO intake.
Initiate Rebound Vitamins: 1 tablet twice daily.
Reassess every 2–4 hours.
Lorazepam 1mg PO/SL. May repeat in 1 hour if CIWA-Ar ≥ 8.
Ensure adequate PO hydration. Monitor vitals.
Rebound Vitamins: 1 tablet twice daily.
Reassess every 1–2 hours.
Lorazepam 2mg PO/SL. May repeat in 1 hour if CIWA-Ar ≥ 10.
Consider IV access. Monitor for escalation.
Rebound Vitamins: 1 tablet twice daily.
Reassess every 1 hour. Continuous monitoring recommended.
Lorazepam 2–4mg IV/IM. May repeat q1h PRN. Consider scheduled dosing.
IV access required. Seizure precautions. Inpatient admission recommended.
Rebound Vitamins: 1 tablet twice daily. IV Thiamine if unable to take PO.
Continuous monitoring. ICU/inpatient hospitalization required.
Lorazepam 4mg IV q15–30 min PRN. Diazepam 10–20mg IV alternative. Phenobarbital if refractory.
INPATIENT HOSPITALIZATION REQUIRED. ICU admission strongly recommended. Seizure precautions. Intubation may be required. Consult toxicology/addiction medicine.
IV Thiamine 100mg before any glucose. Transition to Rebound Vitamins when tolerating PO.
Classic triad present in <20% of WE cases; low threshold for empiric Thiamine recommended.5 IV Thiamine before glucose is standard of care.6
Phenobarbital adjunct shown effective for benzodiazepine-refractory alcohol withdrawal.7
Monitoring & Action Schedule
Step-by-step clinical actions from admission through the 6-week recovery period, including Rebound Vitamins integration at each phase.
- Obtain baseline CIWA-Ar score
- Vital signs (HR, BP, RR, Temp, SpO₂)
- Establish IV access
- Labs: BMP, Mg²⁺, Phos, CBC, LFTs, BAL, urine tox screen
- Initiate Rebound Vitamins 1 tablet PO (if tolerating oral intake)
- Assess for Wernicke's encephalopathy risk — give IV Thiamine 100mg if suspected
- CIWA-Ar every 1–2 hours
- Administer lorazepam per CIWA-Ar score tier
- Reassess vitals with each CIWA-Ar assessment
- Monitor cumulative benzodiazepine dose
- Rebound Vitamins second dose (if not given at admission)
- CIWA-Ar every 2–4 hours if score stable < 10
- Continue symptom-triggered lorazepam per protocol
- Recheck Mg²⁺ and replace if < 1.8 mEq/L
- Rebound Vitamins 1 tablet twice daily — continue
- Reassess need for scheduled benzodiazepine if score trending up
- CIWA-Ar every 4–8 hours if score consistently < 8
- Taper benzodiazepine as clinically indicated
- Rebound Vitamins 1 tablet twice daily through Day 5
- Transition planning: addiction medicine consult, outpatient follow-up
- Discontinue CIWA-Ar monitoring when score < 8 for 24 hours
- Rebound Vitamins 1 tablet once daily for 6 weeks
- Outpatient follow-up with primary care or addiction medicine
- Nutritional counseling and dietary support
- Continued alcohol use disorder treatment (MAT, counseling)
Supplementation Protocol
Rebound Vitamins replaces the Thiamine, Folic Acid, and oral Magnesium orders from the standard UCSF supplementation set. IV Thiamine and IV Magnesium remain available for patients unable to take PO or with severe deficiency.
Routine Thiamine supplementation recommended for all patients undergoing alcohol withdrawal.6 Magnesium repletion reduces seizure risk and supports benzodiazepine efficacy.8 Folate supplementation addresses deficiency common in alcohol use disorder.9
Days 1–5: 1 tablet BID Day 6–6 weeks: 1 tablet daily
With food or water. Initiate at admission if tolerating PO.
Replaces three separate orders. Contains Thiamine (B1), Folate, Magnesium, and full B-complex.
100mg IV/IM × 3 days, then transition to Rebound Vitamins PO
BEFORE any glucose-containing fluids. Give if WE suspected or PO not tolerated.
Wernicke's encephalopathy prevention. Transition to Rebound Vitamins as soon as PO tolerated.
2g IV over 2 hours if Mg²⁺ < 1.2 mEq/L or symptomatic
Based on lab values. Rebound Vitamins provides oral Mg support for mild deficiency.
IV replacement for severe deficiency only. Rebound Vitamins covers mild-to-moderate oral Mg repletion.
Rebound Vitamins Dosing Schedule
Two-phase dosing aligned with the UCSF CIWA-Ar protocol: intensive repletion during active withdrawal, followed by maintenance supplementation through 6 weeks of recovery.
Active withdrawal period — higher-dose repletion
Maintenance and continued nutritional recovery
Standard UCSF Orders vs. Rebound Vitamins
Rebound Vitamins consolidates three separate supplementation orders into one product.
| Standard UCSF Order | Standard Dose | Rebound Vitamins |
|---|---|---|
| Thiamine (Vitamin B1) | 100mg PO/IM/IV daily | ✓ Included — BID × 5 days, then daily × 6 weeks |
| Folic Acid | 1mg PO daily | ✓ Included — BID × 5 days, then daily × 6 weeks |
| Magnesium (oral) | As indicated PO | ✓ Included — BID × 5 days, then daily × 6 weeks |
| Multivitamin | 1 tablet PO daily | ✓ Full B-complex + vitamins C, D, E, zinc included |
| Total separate orders | 4 orders | 1 product — Rebound Vitamins |
Prescribing Guidance — Rebound Vitamins
All patients undergoing CIWA-Ar monitored alcohol withdrawal who are tolerating oral intake. Initiate at admission. Replaces Thiamine, Folic Acid, and oral Magnesium orders.
Days 1–5: 1 tablet twice daily (BID) with water or food. Day 6 through 6 weeks: 1 tablet once daily. Continue through the full recovery period.
If PO not tolerated or Wernicke's encephalopathy suspected: give IV Thiamine 100mg before any glucose. Transition to Rebound Vitamins BID as soon as PO is tolerated.
References
- 1.
Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM. Assessment of alcohol withdrawal: the revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). Br J Addict. 1989;84(11):1353–1357.
- 2.
Saitz R, Mayo-Smith MF, Roberts MS, Redmond HA, Bernard DR, Calkins DR. Individualized treatment for alcohol withdrawal: a randomized double-blind controlled trial. JAMA. 1994;272(7):519–523.
- 3.
Daeppen JB, Gache P, Landry U, et al. Symptom-triggered vs fixed-schedule doses of benzodiazepine for alcohol withdrawal: a randomized treatment trial. Arch Intern Med. 2002;162(10):1117–1121.
- 4.
Peppers MP. Benzodiazepines for alcohol withdrawal in the elderly and in patients with liver disease. Pharmacotherapy. 1996;16(1):49–57.
- 5.
Harper CG, Giles M, Finlay-Jones R. Clinical signs in the Wernicke-Korsakoff complex: a retrospective analysis of 131 cases diagnosed at necropsy. J Neurol Neurosurg Psychiatry. 1986;49(4):341–345.
- 6.
Thomson AD, Cook CC, Touquet R, Henry JA; Royal College of Physicians, London. The Royal College of Physicians report on alcohol: guidelines for managing Wernicke's encephalopathy in the accident and emergency department. Alcohol Alcohol. 2002;37(6):513–521.
- 7.
Rosenson J, Clements C, Simon B, et al. Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo-controlled study. J Emerg Med. 2013;44(3):592–598.
- 8.
Elisaf M, Merkouropoulos M, Tsianos EV, Siamopoulos KC. Pathogenetic mechanisms of hypomagnesemia in alcoholic patients. J Trace Elem Med Biol. 1995;9(4):210–214.
- 9.
Halsted CH, Villanueva JA, Devlin AM, Chandler CJ. Folate deficiency, methionine metabolism, and alcoholic liver disease. Alcohol. 2002;27(3):169–172.
Medical Disclaimer: This page is intended as a clinical reference for licensed healthcare providers. Rebound Vitamins is a nutritional supplement, not a pharmaceutical product, and does not replace clinical judgment or institutional protocol. Always follow your institution's current approved protocol. IV Thiamine and IV Magnesium remain indicated when clinically required regardless of oral supplementation. — Wallace Peoples, C.E.O., W.Peoples Pharmaceuticals
Integrate Rebound Vitamins
Into Your CIWA-Ar Protocol
One product replaces three supplementation orders. Designed for use during active CIWA-Ar monitoring and the 6-week recovery period that follows.