Marjorie Peck, BS, PharmD
Ascension St. Vincent Indianapolis
Indianapolis, Indiana
Disclosure information not submitted.
Joe Bodkin, BCCCP, PharmD
Critical Care Pharmacy Specialist
Franciscan Health Indianapolis, United States
Disclosure information not submitted.
A. Katie Hiles, PharmD, BCPS
Emergency Medicine Pharmacy Specialist
Franciscan Health Indianapolis, United States
Disclosure information not submitted.
David Reeves, PharmD, BCOP
Hematology/Oncology Clinical Pharmacy Specialist
Franciscan Health Indianapolis, United States
Disclosure information not submitted.
Ross E. Heskett, MD
Emergency Medicine Specialist
Franciscan Health Indianapolis, United States
Disclosure information not submitted.
Title: Efficacy and Safety of Phenobarbital in Acute Alcohol Withdrawal Syndrome: A Retrospective Analysis
Introduction: Current guidelines recommend benzodiazepines (BZDs) as first-line therapy for the treatment of severe alcohol withdrawal syndrome (AWS). In this setting, BZDs can often require frequent administration, result in respiratory depression or mechanical ventilation, and lead to prolonged hospital stays when monotherapy fails to control symptoms. Phenobarbital (PHB) poses several pharmacodynamic advantages in the context of acute AWS, including a dual mechanism of action and long duration of action (80-120 hours). The goal of this study is to evaluate the effect of an adjunctive IV PHB protocol on hospital length of stay (LOS). Additional indicators of treatment efficacy and safety include: LOS stratified by level of care; cumulative doses of BZDs administered; use of adjunct medications for refractory symptoms; and incidence of AWS-related complications such as seizures, new-onset delirium tremens (DTs), and the need for mechanical ventilation (MV).
Methods: A retrospective cohort study was performed of patients aged ≥ 18 years who were admitted for the acute management of AWS and treated with either a symptom-triggered, BZD-based protocol alone or in conjunction with intravenous (IV) PHB. PHB was administered as a one-time IV loading dose upon treatment initiation, however repeat doses were permitted for severe symptoms at the attending provider’s discretion.
Results: Of the 239 patients included, 114 (47.7%) received BZD monotherapy and 125 (52.3%) received adjunctive PHB. Although hospital LOS was found to be statistically similar between the PHB and BZD groups (4.4 vs. 5.0 days; p = .252), use of PHB was associated with significant reductions in intensive care unit LOS (1.1 vs. 1.6 days; p = .006), incidence of new-onset DTs (10.4% vs. 25.4%; p = .008), and need for MV (6.4% vs. 14.0%; p = .049).
Conclusions: This study supports favorable efficacy and safety outcomes with use of IV PHB as an adjunct to symptom-triggered BZD therapy in patients hospitalized for acute AWS, specifically with regard to reductions in ICU LOS, incidence of new-onset DTs, mechanical ventilation, and BZD utilization. These findings are consistent with those of prior studies, while also providing additional insight into clinical outcomes and adjunctive medication utilization in patients hospitalized for the management of AWS.