Dutta

8/4/21

UVA Phenobarb protocol

Lowest Level: For patients with no history of DT and are considered moderate
withdrawal risk, phenobarbital can be used as outlined below although in most cases
utilizing a benzodiazepine or a non-benzodiazepine detox will be adequate.
 
Recommendations:
- Day 1: 64.8 mg po TID
- Day 2: 64.8 mg po BID
- Day 3: 32.4 mg po BID
- Day 4: 32.4 mg po x 1
 
- For breakthrough symptoms AFTER phenobarbital has been adequately loaded
AND patient achieves symptom control are atypical. Consider giving phenobarbital
64.8 mg PO q2H PRN if 2 or more of the following are present:
            - SBP >160 or DBP>100
            - HR > 110
            - Diaphoresis
            - Tremor
            - Hallucinations
            - Significant agitation
-       Avoid giving benzodiazepines after phenobarbital has been loaded
-       Once initial alcohol withdrawal symptoms are controlled, if hypertension
develops, ensure that the patient has been restarted on home antihypertensive
agent as many alcohol dependent patients have baseline hypertension.
-       Similarly, if tachycardia develops, ensure that the patient has adequate
hydration and given IVF bolus if clinically appropriate.
-       Delirious agitation may persist despite phenobarbital. This may be due to an
underlying alternative cause for delirium (ie pancreatitis, pneumonia, etc) or due to
delirium tremens. If the patient is agitated but is not showing other signs of
withdrawal, then utilize an antipsychotic for agitation as you would in other cases of
delirium (such as haloperidol 2 mg to 5 mg IV q4 PRN)
- Continue micronutrient repletion per protocol (Thiamine, folate, B12)
- Consider medication assisted treatment of alcohol use disorder upon completed
- Provide patient with local Substance Abuse Treatment information as patient likely
will require ongoing psychosocial support to maintain sobriety
 
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Medium Level: For patients who are early in withdrawal with no active DT but have a
history of DTs, it is acceptable to load phenobarbital orally on acute care or in the
ICU as follows:
 
Recommendations:
 Calculate patient's body weight (~ *** kg)
- Day 1: 6 mg/kg - 8 mg/kg is the loading dose ( *** Example 70 kg ***  ~ 420 mg
total first day loading dose at 6 mg/kg) that should be divided into three doses as
follows:
 Dutta
8/4/21

                        Give 40% (*** Example of 70 kg body weight division *** 100 +

64.8mg tabs = 164.8mg) of total loading dose with the first dose administration
                        After 3 hours (2x 64.8mg tabs = 129.6mg), give 30% of the total
loading dose. Hold if sedated.
                        After 3 hours (2x 64.8mg tabs = 129.6mg), give remaining 30%.
Hold if sedated.
- Day 2: 64.8 mg PO BID
- Day 3: 32.4 mg PO BID
- Day 4 32.4 mg PO once
- Monitor blood pressure
- For breakthrough symptoms AFTER phenobarbital has been adequately loaded
AND patient achieves symptom control are atypical. Consider giving phenobarbital
64.8 mg PO q2H PRN if 2 or more of the following are present:
            - SBP >160 or DBP>100
            - HR > 110
            - Diaphoresis
            - Tremor
            - Hallucinations
            - Significant agitation
-       Avoid giving benzodiazepines after phenobarbital has been loaded
-       Once initial alcohol withdrawal symptoms are controlled, if hypertension
develops, ensure that the patient has been restarted on home antihypertensive
agent as many alcohol dependent patients have baseline hypertension.
-       Similarly, if tachycardia develops, ensure that the patient has adequate
hydration and given IVF bolus if clinically appropriate.
-       Delirious agitation may persist despite phenobarbital. This may be due to an
underlying alternative cause for delirium (ie pancreatitis, pneumonia, etc) or due to
delirium tremens. If the patient is agitated but is not showing other signs of
withdrawal, then utilize an antipsychotic for agitation as you would in other cases of
delirium (such as haloperidol 2 mg to 5 mg IV q4 PRN)
-Continue micronutrient repletion per protocol (Thiamine, folate, B12)
-Consider medication assisted treatment of alcohol use disorder upon completed
- Provide patient with local Substance Abuse Treatment information as patient likely
will require ongoing psychosocial support to maintain sobriety
 
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Highest Level: Any of the following - Active Delirium tremens, history of
benzodiazepine refractory withdrawal, use of  >40mg lorazepam equivalents in 4
hours or 10 mg in 1 hour OR worsening clinical status despite escalating doses (see
full alcohol withdrawal guidelines for details on escalation of care), prior ICU
requirement for alcohol withdrawal. OR History of delirium tremens plus active
withdrawal symptoms as defined by two of the following:
 
  -SBP >160 or DBP >100
-HR >110
-Diaphoresis
-Tremor
-Hallucinations
 Dutta
8/4/21

-Significant agitation (such as RASS >2)

 
Consider sedation risk as well: High risk conferred by age >65, impaired respiratory
status, head trauma, hepatic dysfunction, concomitant sedative/opioid use, C-collar.
Note: Currently parenteral phenobarbital is reserved for use in the critical care
setting.
 
Recommendations:
Day 1: 6mg/kg or 10mg/kg IM or IV based on sedation risk in three divided doses
Day 2: 64.8 mg po BID
Day 3: 32.4 mg po BID
Day 4: 32.4 mg po x 1
- For breakthrough symptoms AFTER phenobarbital has been adequately loaded
AND patient achieves symptom control are atypical. Consider giving phenobarbital
64.8 mg PO q2H PRN if 2 or more of the following are present:
            - SBP >160 or DBP>100
            - HR > 110
            - Diaphoresis
            - Tremor
            - Hallucinations
            - Significant agitation
-       Avoid giving benzodiazepines after phenobarbital has been loaded
-       Once initial alcohol withdrawal symptoms are controlled, if hypertension
develops, ensure that the patient has been restarted on home antihypertensive
agent as many alcohol dependent patients have baseline hypertension.
-       Similarly, if tachycardia develops, ensure that the patient has adequate
hydration and given IVF bolus if clinically appropriate.
-       Delirious agitation may persist despite phenobarbital. This may be due to an
underlying alternative cause for delirium (ie pancreatitis, pneumonia, etc) or due to
delirium tremens. If the patient is agitated but is not showing other signs of
withdrawal, then utilize an antipsychotic for agitation as you would in other cases of
delirium (such as haloperidol 2 mg to 5 mg IV q4 PRN)
- Continue micronutrient repletion per protocol (Thiamine, folate, B12)
- Consider medication assisted treatment of alcohol use disorder upon completed
- Provide patient with local Substance Abuse Treatment information as patient likely
will require ongoing psychosocial support to maintain sobriety