The Growing Role of Phenobarbital in Managing Inpatient Alcohol Withdrawal Syndrome
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2854923
Benzodiazepines have long been the standard treatment for acute alcohol withdrawal syndrome (AWS) in hospitalized patients, often administered using symptom-triggered protocols. However, symptom-triggered protocol scoring is subjective and can be difficult to use in patients unable to reliably report symptoms, while escalating benzodiazepine doses can lead to respiratory depression and delirium. Phenobarbital has emerged as an increasingly popular alternative to benzodiazepines and is now the predominant treatment used for AWS in many US hospitals. Phenobarbital has more predictable pharmacokinetics and acts on both γ-aminobutyric acid (GABA) and glutamate receptors, whereas benzodiazepines act primarily through GABA receptors, yet the evidence supporting this shift in terms of effectiveness and adverse effects in practice has remained surprisingly limited. Much of the available evidence comes from emergency department or protocol-based implementation studies, with few studies directly comparing phenobarbital with long-acting benzodiazepines such as diazepam, which have similar pharmacokinetic properties.
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