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Alcohol Withdrawal Management

I. General Considerations

  • Intubated patients: If receiving a propofol or midazolam infusion, no additional therapy is required while on these infusions.
  • Excluded patients:
    • On essential medications that interact with phenobarbital (e.g., HIV medications)
    • Hepatic encephalopathy
    • Chronic phenobarbital use
    • Pregnant

II. Vitamin Supplementation (All Patients)

  • Thiamine 100 mg PO/PT/IV daily × 3 days
  • Folic acid 1 mg PO/PT daily × 3 days
  • Multivitamin PO/PT daily × 3 days

III. Risk Stratification & Management

A. Low Risk *

  • Phenobarbital 60 mg PO TID × 6 doses
  • Then: Phenobarbital 30 mg PO TID × 6 doses

B. High Risk **

  • Phenobarbital 130 mg PO q1h × 2 doses
    If unable to take PO: Phenobarbital 260 mg IV ×1
  • Then:
    • 100 mg PO TID × 6 doses
    • 60 mg PO TID × 6 doses
    • 30 mg PO TID × 6 doses

C. Active Delirium Tremens (DTs)

  • Phenobarbital 260 mg IV × 1 dose
  • Then:
    • 100 mg PO TID × 6 doses
    • 60 mg PO TID × 6 doses
    • 30 mg PO TID × 6 doses
  • If symptoms uncontrolled → Consider SICU transfer

IV. Additional Information

  • PO dosing preferred unless:

    • Acute symptom management required
    • Lack of enteral access
    • Patient unable to swallow safely
      PO:IV conversion = 1:1

  • Breakthrough withdrawal symptoms despite taper:

    • Phenobarbital 65 mg IV q1h PRN to goal RASS 0 to -1
    • Hold dose if RASS ≤ -2 or RR ≤ 12 → notify provider

  • Avoid benzodiazepines

Dose Considerations

  • Soft max cumulative dose: 20 mg/kg (IBW)

  • Absolute max cumulative dose: 30 mg/kg (IBW)

    • Patients with IBW < 70 kg may need adjusted taper

  • If symptoms persist after 20 mg/kg:

    • Consider alternate diagnoses
    • Additional phenobarbital dosing should be cautious
    • Consult Addiction Psychiatry

  • If total dose reaches 30 mg/kg → Do not give more phenobarbital

V. Alcohol Withdrawal Presentation

A. Signs and Symptoms

  • Nausea/vomiting
  • Tremor
  • Paroxysmal sweating
  • Tachycardia (> 100 bpm)
  • Hypertension
  • Anxiety/agitation
  • Visual, tactile, or auditory hallucinations
  • Clouded sensorium
  • Seizures

Note: Symptoms may begin within 6–48 hours of alcohol cessation and may progress to DTs if untreated.

B. Delirium Tremens (DTs)

  • DTs = alcohol withdrawal symptoms plus acute delirium
  • Occurs in ~5% of patients
  • Presents typically at 48–72 hours, can occur up to 96 hours after last drink

Symptoms include: - Tachycardia - Hypertension - Fevers - Increased respiratory rate / respiratory alkalosis - Hallucinations (visual/auditory) - Marked agitation

  • Symptoms may last up to 5 days
  • Untreated mortality may reach 15%, primarily from aspiration risk
  • Airway protection should be considered in patients with DTs

VI. Risk Stratification Notes

* Low Risk: - Positive Audit C - No history of DTs or alcohol withdrawal seizures

** High Risk: - History of alcohol withdrawal seizures - History of DTs - BAC > 200 - BAC > 100 plus symptoms of withdrawal

VII. Authors

Jennifer Beavers, PharmD, BCPS
Bradley M. Dennis, MD
February 26, 2024

VIII. References

  1. Tidwell WP, Thomas TL, Pouliot JD, et al. Treatment of alcohol withdrawal syndrome: phenobarbital vs CIWA-AR protocol. Am J Crit Care 2018;27(6):454–460.
  2. Nisavic MD, Nejad SH, Isenberg BM, et al. Use of phenobarbital in alcohol withdrawal management. Psychosomatics. 2019;60(5):458–467.
  3. Oks M, Cleven KL, Healy L, et al. Phenobarbital for severe AWS in the MICU. J Intensive Care Med. 2018.
  4. Ammar MA, et al. Phenobarbital Monotherapy for AWS in Surgical-Trauma Patients. Ann Pharmacother. 2021;55(3):294–302. doi:10.1177/1060028020949137.
  5. Kodadek LM, et al. Alcohol-Related Trauma Reinjury Prevention. J Trauma Acute Care Surg. 2020;88(1):106–112.
  6. Fleenor LM, et al. Phenobarbital vs Benzodiazepine for AWS in trauma patients. J Trauma Acute Care Surg. 2024 Mar;96(3):493–498. PMID: 37599414.