Brendon Clough, PharmD
Texas Health Presbyterian Hospital Dallas
Fort Worth, Texas
Disclosure information not submitted.
Lyndsay Sheperd, BCCCP, BCPS, PharmD
Clinical Pharmacy Specialist
Texas Health Presbyterian Hospital Dallas, United States
Disclosure information not submitted.
Title: Escalating Doses of Phenobarbital for Alcohol Withdrawal Inadequately Treated with Lorazepam
Introduction: To determine the difference in benzodiazepine (BZD) requirements in patients receiving escalating doses of phenobarbital (PB) versus standard CIWA-Ar-driven lorazepam doses.
Methods: This study is a retrospective analysis of 60 intensive care unit (ICU) patients with severe alcohol withdrawal to evaluate the safety and efficacy of a recently implemented institution-specific PB protocol. Patients were included who were ≥ 18 years of age, were admitted to Texas Health Presbyterian Hospital Dallas for ≥ 72 hours, showed symptoms of severe alcohol withdrawal (CIWA-Ar ≥ 15), and were treated with symptom-triggered BZD management in the ICU. Patients were excluded who were taking PB or a scheduled BZD prior to admission. Data was collected in a 2:1 ratio of patients receiving treatment per the CIWA-Ar protocol alone to patients receiving the PB protocol in addition to CIWA-Ar. Data in the 40 CIWA-Ar patients was collected on those admitted from January 2018 through September 2019. Data in the 20 PB patients was collected after the implementation of the PB protocol in October 2019. The primary outcome of the study was the difference in BZD doses administered (reported in median lorazepam equivalents) in the first seven days of hospitalization between the two groups. Secondary outcomes included the difference in CIWA-Ar scores before and after PB, difference in utilization of adjunctive pharmacologic agents, duration of mechanical ventilation, incidence of seizures, ICU length of stay, hospital length of stay, readmission rates, and in-hospital mortality. Pre-identified safety outcomes were also assessed.
Results: Patients in the PB group received significantly less BZD in the first seven days of hospital admission (22.2 vs 46.5 mg; p < 0.001). The median CIWA-Ar score in the six hours prior to PB was 16.5 vs 10.5 in the 48 hours after completion of PB (p=0.013). There was no difference between PB and CIWA-Ar in the utilization of 3 or more adjunctive pharmacologic agents (60 vs 60%). ICU LOS was longer in patients who received PB (12.0 vs 10.0 days, p < 0.001), but in-hospital mortality was similar between groups (5.0 vs 5.0%).
Conclusions: Phenobarbital, in escalating doses, is a potentially safe and effective strategy for patients with BZD-refractory alcohol withdrawal.