Phenobarbital for Alcohol Withdrawal: Reviewing the Evidence

Have you tried to use phenobarbital for your ICU patients with alcohol withdrawal syndrome?
Typically, we use benzodiazepines such as ativan to treat this.
Although the empiric data is quite compelling to make the switch.
I personally use phenobarbital more often than benzodiazepines these days.
The main question of course is the dosing.
This single-center, pre-post protocol implementation study is a great starting point for those looking for data.
Hat tip to the authors, read these data for yourself.

Phenobarbital dose/dosing for alcohol withdrawal

Here’s the dosing regimen used by the team for alcohol withdrawal: phenobarbital 260mg IV for one initial dose followed by 130mg IV every 15 to 30 minutes as needed with a max total dose of 15mg/kg of IDEAL body weight. This is aimed at achieving a CIWA-Ar score of less than 10.

What are the benefits?

This protocol shaved off almost a day in the ICU length of stay but three days in the hospital length of stay.
In addition, there was far less use of adjunctive medications such as dexmedetomidine, haloperidol, and gabapentin.
Fewer patients needed to be intubated and fewer needed restraints.

What are the adverse effects of phenobarbital for alcohol withdrawal?

Per this study, they did not find any adverse effects.

I’ve been using phenobarbital in my practice with great success. It’s time for us to consider changing our practice. If your patient has pancreatitis, this is how we should provide them with fluids.


Alwakeel M, Alayan D, Saleem T, Afzal S, Immler E, Wang X, Akbik B, Duggal A. Phenobarbital-Based Protocol for Alcohol Withdrawal Syndrome in a Medical ICU: Pre-Post Implementation Study. Crit Care Explor. 2023 Apr 18;5(4):e0898. doi: 10.1097/CCE.0000000000000898. PMID: 37091477; PMCID: PMC10115550.
Link to Article

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