In this episode of Inpatient Update, Dr. Mason Turner is joined by clinical pharmacist Lindsay Deloney for one big question and three pharmacy quick hits:
- Phenobarbital for alcohol withdrawal — can we safely use a structured IV pathway on the medical floor?
- Steroids + PPIs — does starting glucocorticoids really require gastroprotection?
- Extended anticoagulation — should apixaban 5 mg twice daily live on the medication list forever after a VTE?
- AmpC organisms — when should a ceftriaxone-susceptible result actually make you nervous?
Practical pharmacology, evidence, and a little pharmacist gentle guidance for your next day on service.
Articles
Hospital-Wide Implementation, Clinical Outcomes, and Safety of Phenobarbital for Alcohol Withdrawal
JAMA Network Open, 2025
https://doi.org/10.1001/jamanetworkopen.2025.28694
Hospital-wide implementation of a weight-based IV phenobarbital pathway was associated with:
- Faster improvement in withdrawal symptoms
- ~30 hours shorter treatment duration
- ~2.2 days shorter time to discharge
- No significant increase in intubation, mortality, or other measured safety outcomes
Takeaway
Phenobarbital does not have to be an ED- or ICU-only medication.
The evidence is observational, but a structured, protocolized approach appears feasible on the medical floor.
Steroids + PPI Prophylaxis
Prescribing of Medication to Prevent Glucocorticoid Harms in Patients With Polymyalgia Rheumatica
Arthritis & Rheumatology, 2026
https://doi.org/10.1002/art.70087
Gastroprotection with a PPI or H2 blocker was not associated with fewer serious GI events in patients receiving glucocorticoids.
Things We Do for No Reason™: Routine Use of Proton Pump Inhibitors for Peptic Ulcer Prophylaxis in Adults on High-Dose Corticosteroids
Journal of Hospital Medicine, 2023
https://doi.org/10.1002/jhm.13095
Takeaway
Steroids alone are not an automatic indication for a PPI.
Instead, look for actual GI risk factors: NSAIDs, anticoagulation, antiplatelets, previous GI bleeding, or another independent indication for acid suppression.
Extended Anticoagulation After VTE
Apixaban for Extended Treatment of Venous Thromboembolism — AMPLIFY-EXT
New England Journal of Medicine, 2013
https://doi.org/10.1056/nejmoa1207541
Extended Reduced-Dose Apixaban for Cancer-Associated VTE — API-CAT
New England Journal of Medicine, 2025
https://doi.org/10.1056/nejmoa2416112
Apixaban for Extended Treatment of Provoked Venous Thromboembolism — HI-PRO
New England Journal of Medicine, 2025
https://doi.org/10.1056/nejmoa2509426
RENOVE Trial
Lancet, 2025
https://doi.org/10.1016/s0140-6736(24)02842-3
Takeaway
Don’t let apixaban 5 mg twice daily remain on the medication list indefinitely without asking why.
After the acute VTE treatment period, reassess:
- Does this patient still need extended anticoagulation?
- If so, do they still need full-dose therapy?
- Could reduced-dose anticoagulation preserve benefit while reducing bleeding risk?
The answer depends on recurrence risk, but hospitalization is a great opportunity to revisit the plan.
IDSA 2024 Guidance on Antimicrobial-Resistant Gram-Negative Infections
https://doi.org/10.1093/cid/ciae403
For organisms at meaningful risk of inducible AmpC:
- Enterobacter cloacae complex
- Klebsiella aerogenes
- Citrobacter freundii
A susceptibility report showing “sensitive” to ceftriaxone does not necessarily mean you should use it for an invasive infection.
Takeaway
Remember the AmpC bugs.
For invasive infections with these organisms:
- Avoid reflexive ceftriaxone
- Piperacillin-tazobactam is also not preferred
- Cefepime is generally the preferred option when appropriate
Don’t just read the susceptibility result. Know the organism.
Practice-Changing Takeaways
- Alcohol withdrawal: Phenobarbital can be used beyond the ICU when supported by a structured pathway.
- Steroids: Don’t automatically add a PPI.
- VTE: Reassess chronic full-dose apixaban once the acute treatment period is over.
- AmpC: Enterobacter cloacae, Klebsiella aerogenes, Citrobacter freundii — don’t let a ceftriaxone “S” fool you.
Question the medication list. Know the organism. Use your pharmacist.
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