Carly Boyd, PharmD
Scripps Mercy Hospital San Diego
San Diego, California
Disclosure information not submitted.
Julie Moon, PharmD, BCCCP, BCPS
ICU Pharmacist
Scripps Mercy Hospital San Diego, United States
Disclosure information not submitted.
Harminder Sikand, PharmD, FASHP, FCSHP, FCCP
Director of Clinical Pharmacy Services
Scripps Mercy Hospital San Diego, United States
Disclosure information not submitted.
Title: Phenobarbital Compared to Benzodiazepines for Alcohol Withdrawal Syndrome in the Intensive Care Unit
Introduction: Current American Society of Addiction Medicine (ASAM) guidelines recommend benzodiazepines (BZD) as standard of care for alcohol withdrawal syndrome. Previous studies have demonstrated equal efficacy of phenobarbital (PHB) compared to benzodiazepines. However, the majority of studies have compared phenobarbital as an adjunctive agent to benzodiazepines, which may underestimate the efficacy of phenobarbital. The aim of this study is to assess the efficacy and safety of a phenobarbital monotherapy protocol compared to a benzodiazepine protocol for the treatment of alcohol withdrawal syndrome (AWS).
Methods: Adult patients > 18 years of age admitted to the ICU with a diagnosis of alcohol withdrawal syndrome were included in this retrospective study. Patients were excluded if phenobarbital was prescribed as a home medication, if they were diagnosed with advanced cirrhosis or pregnant. The primary outcomes were length of ICU stay, duration of mechanical ventilation, and duration of alcohol withdrawal syndrome. Secondary outcomes included complications of alcohol withdrawal, adverse events, and mortality.
Results: A total of 48 patients (PHB= 9, BZD= 27, BZD + PHB= 12) were included in the analysis. There was a significant overall difference among PHB, BZD, and BZD + PHB for ICU length of stay, duration of mechanical ventilation, and duration of AWS [1.75 vs 2.36 vs 6.27, p=0.041; 0 vs 0 vs 2.35, p=0.037; 3 vs 5 vs 6.5, p=0.047, respectively). Post hoc pairwise comparisons of the primary outcomes did not demonstrate any significant differences. Clinically significant overall differences were demonstrated for delirium tremens (33.3% vs 40.7% vs 83.3%), hallucinations (44.4% vs 25.9% vs 75%), and intubation (11.1% vs 44.4% vs 66.7%) among PHB, BZD, and BZD + PHB, respectively.
Conclusion: This is the first study evaluating phenobarbital monotherapy in the ICU for the treatment of alcohol withdrawal syndrome. There was a trend towards a reduction in ICU length of stay, duration of alcohol withdrawal syndrome, intubation, and delirium tremens with phenobarbital monotherapy, however, larger prospective studies in ICU patients are needed to confirm these results.