Phenobarbital vs Benzos for Alcohol Withdrawal – New Meta-analysis
December 14, 2023
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Written by Caitlin Nicholson
This systematic review and meta-analysis did not show significant improvement in measured patient outcomes for treatment of alcohol withdrawal syndrome with phenobarbital vs benzodiazepines.
Are barbs having a renaissance?
The focus of this study was to compare phenobarbital to benzodiazepines for treatment of alcohol withdrawal syndrome in the ED. The primary outcome focused on proportion of patients admitted to an ICU from the ED. 6 of 8 studies reported hospital admission rates with 5 reporting ICU admission rates. Rates of ICU admission between the treatment groups were statistically insignificant (RR 0.96, p=0.115). Similarly, secondary outcomes measured were also found to be statistically insignificant, including hospital admission (RR 0.98, p=0.146), and re-admission to the ED (RR 1.10, p=0.232).
With regard to pharmacologic outcomes, the authors reported a large difference in combined sedative-hypnotic dose. Patients treated with benzodiazepines alone received a mean sedative-hypnotic dose of 10.7 lorazepam equivalents, whereas patients receiving any phenobarbital received a sedative-hypnotic dose of 30.1 lorazepam equivalents.
The authors mention significant confounding variability with regard to hospital utilization outcomes due to differences in local practice patterns, resource availability, and clinician comfort with treatment and disposition.
How will this change my practice?
Where I practice, there are cultural preferences that play a significant role in treatment choices for alcohol withdrawal syndrome. The authors mention the RCT by Rosenson et al published in 2013 that found a significant difference in admission rates to ICU in favor of patients treated with a one-time dose of phenobarbital combined with symptom-guided lorazepam vs lorazepam alone. Given the null outcome found in this meta-analysis, I will continue to treat based on the current agreed upon practice patterns at my institution with symptom guided benzodiazepines. Further investigation into hospital utilization and appropriate sedative-hypnotic dosing with phenobarbital treatment is needed.
Phenobarbital Treatment of Alcohol Withdrawal in the Emergency Department: A Systematic Review and Meta-analysis. Acad Emerg Med. 2023 Nov 3. doi: 10.1111/acem.14825. Online ahead of print.