Shifting Paradigms: Phenobarbital Monotherapy in Management of Alcohol Withdrawal

Document Type

Conference Proceeding

Publication Date

10-2025

Publication Title

Chest

Abstract

PURPOSE: Alcohol withdrawal syndrome (AWS) is a potentially life-threatening condition that can lead to severe autonomic instability, seizures, and delirium tremens. Benzodiazepines (BZD) have traditionally been the mainstay of treatment; however, phenobarbital (PHB) is gaining traction due to its long half-life, and ability to mitigate withdrawal symptoms effectively. Despite its increasing use, there remains variability in treatment protocols, and comparative data between phenobarbital and benzodiazepine-based regimens are limited. This study aims to compare the use of PHB only vs PHB + BZD among patients hospitalized with AWS. METHODS: A retrospective study was conducted after an institutionally approved weight-based PHB protocol was implemented on patients hospitalized with AWS. Data was collected from October 2023 and November 2024. Patients who received a loading dose of phenobarbital were included, regardless of whether benzodiazepines were administered before its initiation. Data collection included demographic characteristics, initial withdrawal severity based on (CIWA score), treatment regimens, total phenobarbital dosing, time to symptom resolution, and length of hospital stay. Patients were categorized into mild, moderate, and severe withdrawal based on PHB only group vs PHB + BZD group using CIWA scores. Descriptive statistics were used to summarize the findings using R. RESULTS: A total of 111 patients were enrolled in the PHB only group (N=32) and PHB + BZD group (N=79). The majority of patients were male ~80% in both groups. The percentage of patients who received only phenobarbital was 29%, while patients who received Phenobarbital in addition to Benzodiazepines was 71%. Mild AWS PHB only group (n=9) received a mean of 8.9mg vs 9.1mg/kg IBW in PHB+BZD group (n=16). Moderate AWS PHB only group (n=10) received a mean of 10.1mg vs 8.8mg in the PHB+BZD group (n=36). Severe AWS PHB only group (n=11) received a mean of 11.1mg vs 11.4mg in PHB+BZD group (n=22). 66 % of patients in the PHB only group required Taper of PHB vs 71% in PHB + BZD. Time to symptom resolution in PHB only was 1.7 days vs 2.7 in PHB + BZD group (p< 0.0001). LOS in PHB only group was lower by 0.8 days compared to the PHB+BZD group. CONCLUSIONS: PHB when used as monotherapy significantly reduced time to symptom resolution and also reduced LOS compared to PHB + BZD. Remarkably our patient population required a lower loading dose than standard protocol recommendations for resolution of symptoms. Our patients were also noted to respond better to PHB only compared to PHB with BZD and requiring less taper of medications possibly due to BZD causing delirium. Though our sample size is small we have clear signals of the superiority of PHB monotherapy in the management of AWS. Variability in dosing and tapering strategies suggests a need for standardized protocols to help establish best practices and improve patient outcomes. CLINICAL IMPLICATIONS: PHB monotherapy significantly reduced symptom resolution time and LOS compared to PHB + BZD, required lower loading doses, minimized tapering needs, and showed superiority in AWS management, highlighting the need for standardized protocols.

Volume

168

Issue

4S

First Page

4527A

Last Page

4528A

Comments

American College of Chest Physician CHEST Annual Meeting, October 19-22, 2025, Chicago, IL

DOI

10.1016/j.chest.2025.07.2531

Link to Full Text

Share

COinS