Comparing Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar)-Guided Benzodiazepine Versus Richmond Agitation-Sedation Scale (RASS)-Guided Phenobarbital Management for Alcohol Withdrawal Syndrome in Hospitalized Patients.

BACKGROUND: Alcohol withdrawal syndrome (AWS) is a common and potentially severe complication of abrupt alcohol cessation. Benzodiazepines (BZD) guided by the Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) scale are commonly used to manage alcohol withdrawal, but objective alternatives may improve outcomes. Phenobarbital (PB) guided by the Richmond Agitation-Sedation Scale (RASS) has emerged as a potential alternative. This study aimed to compare clinical outcomes in hospitalized patients with AWS receiving CIWA-Ar-guided BZD versus RASS-guided PB therapy. METHODS: This retrospective cohort study included adults hospitalized with AWS across a multicenter health system in the Upper Midwest of the United States. Patients treated under the CIWA-Ar-guided BZD therapy from June 1, 2024 until August 31, 2024, were compared with those treated under the RASS-guided PB therapy from June 1, 2025 to August 31, 2025. Primary outcomes were mechanical ventilation and non-invasive ventilation (NIV) requirements. Secondary outcomes included hospital length of stay (LOS), need for intensive care unit (ICU) care, and ICU LOS. RESULTS: A total of 125 patients were included (BZD, n = 46; PB, n = 79). Mechanical ventilation and NIV requirements were infrequent and were not statistically significantly different between groups (mechanical ventilation: 4.3% vs 1.3%, P = .554; NIV: 2.2% vs 5.1%, P = .651). RASS-guided PB therapy was associated with a shorter hospital LOS compared with CIWA-Ar-guided BZD therapy (median 3.5 days [interquartile range (IQR) 2-6.75] vs 3 days [IQR 2-4]; P = .025). Patients receiving BZD were more likely to require ICU care than those receiving PB (47.8% vs 26.6%, P = .016). Among patients requiring ICU care, ICU LOS did not differ between groups (median 2 days [IQR 1-3.75] vs 2 days [IQR 1-3]; P = .97). CONCLUSION: RASS-guided PB therapy in hospitalized patients with AWS was associated with a shorter hospital stay and a lower need for ICU care compared with CIWA-Ar-guided BZD therapy. In contrast, ICU LOS and respiratory outcomes were comparable between groups. These results suggest that RASS-guided PB therapy may be associated with reduced escalation to ICU-level care without evidence of increased adverse respiratory events.