Hospital Management of Alcohol Withdrawal Syndrome: Symptom-Triggered Strategies and the Use of Phenobarbital

Abstract

Introduction: Alcohol withdrawal syndrome (AWS) is a frequent and potentially severe complication among hospitalized patients with alcohol use disorder. In recent years, therapeutic strategies based on symptom-triggered monitoring and the use of phenobarbital have emerged as alternatives to traditional fixed-dose benzodiazepine regimens. Methodology: A narrative review of the scientific literature was conducted using PubMed, Web of Science, Scopus, and SciELO databases, including publications from 2010 to 2026. Studies addressing symptom-triggered protocols, clinical monitoring scales, and the use of phenobarbital in hospitalized adult patients with AWS were analyzed. Results: Symptom-triggered protocols using tools such as CIWA-Ar and mMINDS were consistently associated with lower cumulative benzodiazepine exposure and reduction of certain adverse outcomes, including progression to delirium tremens and hospital readmissions. Phenobarbital demonstrated utility as an adjunctive therapy in moderate and severe AWS, particularly in benzodiazepine-refractory patients, and was associated with lower intensive care unit admission requirements and reduced overall sedative use. However, the predictive performance of clinical scales for identifying progression to critical forms of AWS remained limited. Discussion: The available evidence supports a transition toward more individualized and protocolized therapeutic models. Nevertheless, significant methodological heterogeneity and institutional variability persist across the available studies. Conclusion: Symptom-triggered strategies and phenobarbital represent promising alternatives for optimizing the hospital management of AWS. Prospective multicenter studies are needed to better define their efficacy, safety, and clinical applicability.