UMEM Educational Pearls

Title: Is there an alternative therapy to benzodiazepine in the treatment of alcohol withdrawal syndrome?

Keywords: alcohol withdrawal syndrome, phenobarbital (PubMed Search)

Posted: 11/29/2018 by Hong Kim, MD
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Alcohol withdrawal syndrome is frequently treated with benzodiazepines following CIWA-Ar (Clinical Institute Withdrawal Assessment of Alcohol scale). There are other medications that are used as either second line or as adjunctive agents along with benzodiazepines. A retrospective study compared the clinical outcomes between phenobarbital vs. benzodiazepines-based CIWA-Ar protocol to treat AWS.

The primary was ICU length of stay (LOS); secondary outcome were hospital LOS, intubation, and use of adjunctive pharmacotherapy.

Study sample: 60 received phenobarbital and 60 received lorazepam per CIWA-Ar.

Phenobarbital protocol:

Active DT: 260 mg IV x 1 dose -> 97.2 mg PO TID x 6 doses -> 64.8 mg PO TID x 6 doses -> 32.4 mg PO TID x 6 doses
History of DT: 97.2 mg PO TID x 6 doses -> 64.8 mg PO TID x 6 doses -> 32.4 mg PO TID x 6 doses
No history of DT: 64.8 mg PO TID x 6 dose -> 32.4 mg PO TID x 6 doses.

Results

	Phenobarbital	CIWA-Ar
ICU LOS	2.4 days	4.4 days
Hospital LOS	4.3 days	6.9 days
Intubation	1 (2%)	14 (23%)
Adjunctive agent use	4 (7%)	17 (27%)

Conclusion

Phenobarbital therapy appears to be a promising alternative therapy for AWS. However, additional studies are needed prior to adapting phenobarbital as first line agent for AWS management.

References

Tidwell WP et al. Treatment of alcohol withdrawal syndrome: phenobarbital vs. CIWA-Ar protocol. Am J Crit Care. 2018 Nov;27(6):454-460. PMID: 30385536.