Title: Comparative Review of Phenobarbital Versus Lorazepam for the Treatment of Acute Alcohol Withdrawal
Investigators: Olivia Langlois, PharmD, Christopher Devine, PharmD, BCPS, BCCCP, Alexis Small, PharmD, BCPS, Jessica Marx, PharmD, BCPS
Learning Objective: By the conclusion of this presentation, participants will be able to compare the safety and efficacy of phenobarbital and lorazepam for the treatment of acute alcohol withdrawal.
Objective: This study aims to evaluate safety and efficacy outcomes of lorazepam guided by the CIWA-Ar protocol versus phenobarbital per hospital-specific pharmacy dosing protocol in the management of inpatient acute alcohol withdrawal.
Methods: This retrospective study reviewed patients admitted with a diagnosis of acute alcohol withdrawal. Patients included all hospitalized adults greater than 18 years old treated for acute alcohol withdrawal with either lorazepam per CIWA-Ar protocol or phenobarbital per pharmacy dosing protocol from April 1, 2025 to July 31, 2025 at a 240-bed academic teaching hospital in Portsmouth, New Hampshire. Patients transferred from outside facilities already receiving either medication were excluded. Data was extracted from the hospital’s electronic health record system. All data was de-identified and securely stored for analysis. Primary outcomes include the length of hospital stay and need for transfer to the intensive care unit. Secondary outcomes assessed the incidence of seizures and acute hypoxic respiratory failure from overmedication leading to intubation. This research was deemed exempt from Institutional Review Board (IRB) oversight in accordance with institutional policy.
Results: A total of 202 patients met inclusion criteria; 73 received lorazepam and 129 received phenobarbital. The baseline characteristics were similar between the two groups. The mean length of hospital stay in the lorazepam and phenobarbital groups was 6.16 days and 7.77 days, respectively (p = 0.236). Eleven (8.5%) patients receiving phenobarbital were transferred to the intensive care unit due to alcohol withdrawal versus 4 patients (5.5%) receiving lorazepam (p = 0.214). Five (3.9%) patients receiving phenobarbital had a reported seizure versus 2 (2.7%) patients receiving lorazepam (p = 0.336). The incidence of acute hypoxic respiratory failure was low, with 3 (2.3%) in the phenobarbital group and 3 (4.1%) in the lorazepam group (p = 0.237).
Conclusion: There was no statistical difference between phenobarbital and lorazepam for the treatment of acute alcohol withdrawal for the outcomes above. Patients in the phenobarbital group, however, had a higher incidence of withdrawal seizures and delirium tremens at baseline, putting them at higher risk of adverse outcomes. About half the patients in the phenobarbital group with an adverse outcome received a suboptimal loading dose; and only a small percentage of patients completed the taper.
Self-Assessment Question: Which of the following is true based upon the results of the study “Comparative Review of Phenobarbital Versus Lorazepam for the Treatment of Acute Alcohol Withdrawal”?
- Phenobarbital is associated with fewer alcohol withdrawal-related seizures than lorazepam
- Patients who received phenobarbital are at an increased risk of developing acute hypoxic respiratory failure compared to lorazepam
- For patients seeking alcohol withdrawal treatment in the inpatient setting, lorazepam was associated with a longer average length of hospital stay versus phenobarbital
- Further research is needed to determine a standardized loading dose and duration of therapy for phenobarbital to treat acute alcohol withdrawal
Disclaimer: This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the authors and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
