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Alcohol Withdrawal – Should We Reach for Phenobarbital?

December 26, 2022

Written by Kathryn Sulkowski

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Hospital adoption of phenobarbital for severe alcohol withdrawal syndrome (SAWS) was associated with lower rates of invasive mechanical ventilation (IMV).

Why does this matter?
Severe alcohol withdrawal syndrome (SAWS) has traditionally been treated with high dose benzodiazepines, which can lead to oversedation thus intubation. Smaller single center studies implementing phenobarbital have shown decreased IMV rates and shorter lengths of stay (LOS); however, there have been no multicenter trials. This study explores phenobarbital use and outcomes across the U.S. to see if outcomes translate to a larger cohort.

A Barb in Classical Management of Withdrawal
This was a multicenter retrospective cohort that looked at 13,000 patients in ICUs across the US. Data came from the Premier Healthcare Database and assessed patients with an admitting diagnosis of alcohol withdrawal who also received benzodiazepines and/or phenobarbital. Eleven percent of the study population received phenobarbital (91% of those also received benzodiazepines).

The primary outcome was IMV, with secondary outcomes of LOS and adjunct medication usage. Subanalysis also compared hospitals that changed their SAW policies during this time and adopted phenobarbital use to those who did not. During the study years there was a 200% increase in phenobarbital use at the adopters’ hospitals, and benzodiazepine use remained stable. There was an association with lower probability of IMV (difference 3.6% (95%CI -6.9 to -0.3) for patients admitted to adopter hospitals vs. those who did not adopt a phenobarbital policy. This translated to an adjusted risk difference of -4.6% (95%CI -5.1 to -0.4) when looking at the IMV rate between patients exposed to phenobarbital and those who weren’t.

Inconsistent adjunct medication dosing and treatment protocols between hospitals hinder discovery of the true effect of phenobarbital in treatment. A prospective trial comparing combination therapy and monotherapy is going to be needed to truly explore the utility (or risk) of phenobarbital in management of SAWS.

Peer Reviewed by Dr. Ketan Patel

Phenobarbital for Severe Alcohol Withdrawal Syndrome: A Multicenter Retrospective Cohort Study. Am J Respir Crit Care Med. 2022 Nov 1;206(9):1171-1174. doi: 10.1164/rccm.202203-0466LE.

What are your thoughts?