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As hospitals refine their alcohol withdrawal pathways, clinicians are weighing when phenobarbital protocols or traditional benzodiazepine strategies are the right fit. For every case, the care team must weigh the patient's stability, history of severe withdrawal, and monitoring capabilities to determine the most effective treatment strategy.
How comfortable are you with managing phenobarbital tapers for a patient in withdrawal? Log in or sign up to share your approach and see the consensus.
Post:
A 52-year-old man with a long history of alcohol use disorder is admitted for withdrawal symptoms — tremors, diaphoresis, anxiety, and tachycardia. He is alert, oriented, and cooperative. CIWA score is 14 on admission. He has no history of withdrawal seizures or delirium tremens.
The hospital recently adopted a phenobarbital-based withdrawal protocol, but most residents and hospitalists are still more familiar with symptom-triggered lorazepam tapers. The patient is being admitted to a general medicine floor, not the ICU.
The hospital recently adopted a phenobarbital-based withdrawal protocol, but most residents and hospitalists are still more familiar with symptom-triggered lorazepam tapers. The patient is being admitted to a general medicine floor, not the ICU.
Questions for consult
How comfortable are you managing phenobarbital tapers on a general medicine floor compared with lorazepam-based protocols?
Comments
Key takeaways about phenobarbital protocols for treating alcohol withdrawal:
- Lorazepam remains the default, but phenobarbital use is rising
Many clinicians still lean on lorazepam out of familiarity, though shortages and growing comfort have increased phenobarbital use. - The “right” protocol depends on patient factors and monitoring
Severity, liver function, prior withdrawal history, and available monitoring determine whether phenobarbital or lorazepam is safer. - Phenobarbital has practical benefits—when the setting supports it
Its long half-life and built-in taper are advantages, but some clinicians prefer higher-acuity settings given the risk of rapid deterioration.
Hospitalist
"I’m certainly more comfortable with managing alcohol withdrawal with the use of lorazepam; however, given the shortages, there has been a recent change to the use of phenobarb for alcohol withdrawal management. As time goes on, I am becoming more comfortable with its use."
Internal Medicine
"Either drug can be used. If the clinicians managing the patient are more familiar with lorazepam, then I feel that would be the drug of choice. Whichever drug is chosen, this patient needs close monitoring. Delirium tremens is a life-threatening problem. Overtreatment presents the risk of respiratory suppression. A drug with a shorter half-life is probably a safer treatment."
Internal Medicine
"As long as the patient is relatively stable, doesn't have severe liver disease, and hasn't received a lot of benzo already(causing sedation), then phenobarbital could be safely used instead of classic benzo treatment. Phenobarbital has the same MOA as benzo, but an additional MOA as well. It has a longer half-life, which is an advantage and causes less agitation and delirium than benzo. It also has a tapering effect and allows you to discharge a patient to home without the need for any other prescriptions."
Internal Medicine
"I prefer any alcohol withdrawal patient to be in a higher-level care setting. They can turn on a dime. Changes that likely won’t be caught in a timely manner on the regular floor."
Internal Medicine
"It depends on the score on the withdrawal scale and history. If they have a history of DT or seizures, definitely monitor. If no history and score is low to moderate, a fixed dose protocol on a general floor is fine."
How would you suggest this practitioner approach managing this case of withdrawal? Read the full post on Healthcasts to see other practitioner perspectives and leave a comment.
