Mahmoud Ammar, BCCCP, PharmD, BCPS,
Critical Care Pharmacist
Yale New Haven Hospital
New Haven, Connecticut
Disclosure information not submitted.
Abdalla Ammar, PharmD, BCCCP, BCPS,
Critical Care Pharmacist, Neurocritical Care
New York Presbyterian Hospital - Weill Cornell Medical College
New York, NY
Disclosure information not submitted.
Bryan McGill, PharmD,
Senior Pharmacy Specialist, Critical Care
Yale New Haven Health, United States
Disclosure information not submitted.
Ginger Rouse, BCCCP, PharmD, BCPS,
Clinical Pharmacy Specialist II, Medical Intensive Care
Yale New Haven Hospital
New Haven, Connecticut
Disclosure information not submitted.
Aashu Patel, PharmD
Clinical Pharmacist
Clovis Community Medical Center, California, United States
Disclosure information not submitted.
Robert Becher, MD, MS
Trauma Surgery and Surgical Critical Care
Yale New Haven Hospital, Connecticut, United States
Disclosure information not submitted.
Title: Phenobarbital versus Benzodiazepines for Alcohol Withdrawal Management: A Retrospective Comparison
Introduction: Benzodiazepine (BZD)-based regimens are first-line therapy for alcohol withdrawal syndrome (AWS). Phenobarbital (PHB) is an alternative treatment but with limited guidance for use. We evaluated the efficacy and safety of PHB compared to BZD for AWS.
Methods: This was a single-center retrospective cohort study. Adult patients were included if they received BZD symptom-triggered protocol or PHB monotherapy for management of AWS and excluded if they received both therapies, were COVID positive, or died within 48 hours of hospital admission. Data collection started on December 31, 2020 and data were collected in reverse chronological order until target sample size was attained. Primary endpoint evaluated was development of AWS-related complications. Secondary endpoints included need for adjunct therapy, duration of mechanical ventilation, hospital and ICU length of stay (LOS), and hospital mortality. Safety endpoints included incidence of hypotension, bradycardia, and significant respiratory depression.
Results: 100 patients out of 164 screened patients were included, with 50 patients in PHB and 50 patients in BZD cohorts. Baseline characteristics were similar, except more patients in PHB cohort had history of alcohol dependence (82% vs. 56%, p< 0.001). Majority of BZD patients were in medical ICU while PHB patients were in surgical ICU. Baseline median MINDS scores were similar [PHB, 10 (5–16) vs. BZD, 11 (5–15), p=0.99]. Median (IQR) phenobarbital loading dose given was 14.8 (12.8–15.9) mg/kg followed by maintenance dose 356 (259-389) mg with a duration of 5 (3–5) days. Total lorazepam-equivalent dose given was 19.3 (5.0–44.0) mg with a duration of 4 (3–5) days. There was no significant difference in the primary endpoint [4 (8%) vs. 4(8%), p=1.00]. MINDS score post therapy initiation was significantly higher in BZD cohort [5 (1–14) vs. 15 (8–19), p< 0.001]. Patients who received PHB therapy had significantly shorter ICU LOS in days [3 (1–7) vs. 5 (2–6), p< 0.001] but no difference in hospital LOS [PHB, 8 (5–13) vs. BZD, 7 (5–12), p=0.37]. There were no significant differences in other secondary and safety endpoints.
Conclusion: In this study there was no difference in efficacy or safety of PHB in management of AWS compared to BZD. Larger studies to confirm PHB as first-line AWS therapy are warranted.