A Comparison of Phenobarbital Dosing Strategies for the Treatment of Alcohol Withdrawal Syndrome.

Authors

Pavan Sastry, Jessica Hasty, Jane Litwak, Victor Zach, Joseph F Sucher, Jeffrey F Barletta

Published in

The Annals of pharmacotherapy. Pages 10600280261455107. Jun 28, 2026. Epub Jun 28, 2026.

Abstract

The preferred dosing strategy for phenobarbital in alcohol withdrawal syndrome (AWS) is not well established.
We compared the effects of a 10- vs 20-mg/kg dose on the incidence of severe AWS and benzodiazepine use.
This retrospective cohort study included patients who received a phenobarbital front-loaded dose with either 10 mg/kg or 20 mg/kg. The primary endpoints were severe AWS (Clinical Institute Withdrawal Assessment [CIWA] score ≥15, use of restraints, or seizures) and total lorazepam equivalents. Secondary endpoints were the frequency of intubation and intensive care unit (ICU) length of stay.
We included 135 patients (n = 71, 10 mg/kg; n = 64, 20 mg/kg). Demographics were similar except baseline CIWA, cirrhosis history, and benzodiazepine administration pre-phenobarbital were higher in the 10-mg/kg group. The incidence of severe AWS was higher in the 10-mg/kg group (56.3% vs 32.8%; P = .006), as was lorazepam administration 48-hour post-phenobarbital load (7 ± 10.3 vs 2.6 ± 5.9 mg; P < .001). After controlling for differences in baseline CIWA scores, there was no difference in severe AWS (odds ratio [OR] [95% CI] = 0.532 [0.215 to 1.315]), but benzodiazepine usage was lower in the 20-mg/kg group (B = -3.376, P = .046). The frequency of new intubation was 5.9% and 10.2% for the 10- and 20-mg/kg groups, respectively (P = .483). No difference in ICU length of stay was noted (10 mg/kg, 4.5 ± 3.4 vs 20 mg/kg, 3.9 ± 3.6; P = .411).
A 20-mg/kg phenobarbital dose did not reduce severe AWS but may lower benzodiazepine usage in the early withdrawal period. A 20-mg/kg dose was not associated with increased intubations. Clinicians may consider this option when crafting phenobarbital dosing regimens in patients with severe AWS.

PMID:
42365467
Bibliographic data and abstract were imported from PubMed on 28 Jun 2026.

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