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Nishimura Y, Choi H, Colgan B, Kistler H, Mercado F. Current evidence and clinical utility of phenobarbital for alcohol withdrawal syndrome. Eur J Intern Med 2023; 112:52-61. [PMID: 36935249 DOI: 10.1016/j.ejim.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 02/28/2023] [Accepted: 03/06/2023] [Indexed: 03/21/2023]
Abstract
BACKGROUND Phenobarbital (PB) has been acknowledged among clinicians as a potential alternative to benzodiazepines (BZD) to decrease the need for hospital length of stay and complications associated with alcohol withdrawal syndrome (AWS). However, the level of evidence, including appropriate dosing, is unclear. We aim to summarize the evidence regarding PB used in AWS and provide future agendas for research. METHODS Following the PRISMA guidelines, we searched MEDLINE, EMBASE, ClinicalTrials.gov, and WHO ICTRP for all peer-reviewed articles and clinical trials using keywords including"alcohol withdrawal", "delirium tremens", "phenobarbital," and "barbiturate" from their inception to September 18, 2022. RESULTS We included 20 articles, nine in the emergency department (ED) and 11 in the general floors or intensive care units (ICUs). Studies performed in the ED included two RCTs, although both suffered from a considerably small sample size. Six studies done in the general floors or ICUs compared PB and BZD monotherapy, while four compared the utility of adjunct PB in addition to BZD compared with BZD monotherapy and one was a database study without specific dosing information. Overall, there was considerable heterogeneity in PB dosing, measured outcomes, and AWS severity measurement scales. CONCLUSION This systematic review summarizes the current evidence related to PB use in AWS. While considerable heterogeneity exists among studies available, PB as monotherapy without BZD may be a safe and effective alternative in AWS treatment. Future prospective studies or trials should focus on the standardization of PB dosing and outcomes.
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Affiliation(s)
- Yoshito Nishimura
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI, 96813, United States of America.
| | - Horyun Choi
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI, 96813, United States of America
| | - Bridget Colgan
- Department of Medicine, Tripler Army Medical Center, Honolulu, HI 96859, United States of America
| | - Harrison Kistler
- Department of Medicine, Tripler Army Medical Center, Honolulu, HI 96859, United States of America
| | - Francisco Mercado
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI, 96813, United States of America; Department of Medicine, Tripler Army Medical Center, Honolulu, HI 96859, United States of America
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Pistore A, Penney S, Bryce R, Meyer C, Bouchard B. A retrospective evaluation of phenobarbital versus benzodiazepines for treatment of alcohol withdrawal in a regional Canadian emergency department. Alcohol 2022; 102:59-65. [PMID: 35569673 DOI: 10.1016/j.alcohol.2022.05.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 05/02/2022] [Accepted: 05/06/2022] [Indexed: 11/01/2022]
Abstract
Evidence suggests that phenobarbital can be used to treat alcohol withdrawal syndrome as monotherapy; however, the therapeutic cornerstone remains benzodiazepines. To date, studies comparing the two treatment modalities in the emergency department (ED) are few. We sought to determine whether phenobarbital versus benzodiazepine monotherapy impacts ED length of stay and need for admission among adult presentations at a single regional hospital. In June 2019, a treatment algorithm offering both phenobarbital and diazepam pathways was introduced at the Battlefords Union Hospital ED, an 11-bed unit treating 27 000 patients annually in North Battleford, Saskatchewan, Canada. A subsequent retrospective observational study evaluated all adult alcohol withdrawal syndrome presentations between June 2019 and January 2021. Medical records were reviewed for visit date, age, sex, comorbidities, psychosocial factors, Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scores, secondary diagnoses, time of day, protocol adherence, attending physician, length of stay, disposition, and ED return. Descriptive statistics, log-rank testing, simple regression, and multiple regression were used in analysis. Of the 184 presentations, 30.4% were treated with phenobarbital. Median length of stay for phenobarbital versus benzodiazepine therapy was 4.4 h and 4.4 h, respectively (p = 0.21). Of the phenobarbital presentations, 9.4% were hospitalized versus 17.1% of the benzodiazepine presentations (p = 0.20). When adjusted for confounders, phenobarbital-treated presentations were 71.3% less likely to be admitted (p = 0.03). This research suggests that phenobarbital performs similarly to benzodiazepines regarding alcohol withdrawal ED length of stay and may result in reduced hospitalizations.
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Filewod N, Hwang S, Turner CJ, Rizvi L, Gray S, Klaiman M, Buell D, Ailon J, Caudarella A, Ginocchio GF, Santos M, Sandhu G, Dewhurst N, Sequeira K, Burns KEA. Phenobarbital for the management of severe acute alcohol withdrawal (the PHENOMANAL trial): a pilot randomized controlled trial. Pilot Feasibility Stud 2022; 8:14. [PMID: 35065662 PMCID: PMC8783453 DOI: 10.1186/s40814-021-00963-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 12/21/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Benzodiazepines are considered first-line treatment for patients experiencing severe acute alcohol withdrawal syndrome (sAAWS). Although several medications have been evaluated as potential adjuvant treatments for sAAWS, barbiturates show particular promise. OBJECTIVE In the PHENOMANAL trial, we will assess the feasibility of conducting an allocation-concealed, quadruple-blinded, randomized controlled trial (RCT) comparing symptom-triggered benzodiazepine therapy with either a single dose of adjuvant intravenous (IV) phenobarbital (7.5 mg/kg of ideal body weight) or a single dose of matching IV placebo for patients with sAAWS. METHODS We will recruit adult patients from the Emergency Department, Intensive Care Unit, or hospital wards with a Clinical Institute of Withdrawal - Adult revised (CIWA-Ar) score of 16 or more after receipt of at least 60 mg of diazepam or equivalent within 16 h of diagnosis of sAAWS, and an anticipated need for hospitalization. We will randomize participants (n=39) in a 2:1 manner to treatment and placebo groups, respectively. The primary objective of the PHENOMANAL pilot trial will be to demonstrate our ability to recruit the desired population over the trial period. As secondary objectives, we will evaluate clinician compliance with the treatment protocols, assess crossover rates from the placebo arm to the treatment arm, and obtain preliminary estimates of treatment effect. All trial participants will be followed for 7 days or until hospital discharge. RELEVANCE The PHENOMANAL trial is novel in investigating a new treatment for a common and understudied condition, repurposing an existing medication for a novel indication, and addressing an important evidence gap. Through conduct of the multidisciplinary pilot trial, we aim to advance methodology in acute care research through the use of a hybrid consent model and inform the design of a large-scale trial. TRIAL REGISTRATION ClinicalTrials.gov Registration NCT03586089 ; first registered July 13, 2018.
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Affiliation(s)
- Niall Filewod
- Trillium Health Partners, Mississauga, Ontario, Canada
| | - Stephen Hwang
- Unity Health Toronto - St. Michael's Hospital, Toronto, Ontario, Canada
- Divisions of Critical Care, Internal Medicine, Emergency Medicine, Psychiatry, Addictions, Family Medicine, and Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
- Map Centre for Urban Health Solutions, Toronto, Canada
| | | | - Leena Rizvi
- Unity Health Toronto - St. Michael's Hospital, Toronto, Ontario, Canada
| | - Sara Gray
- Unity Health Toronto - St. Michael's Hospital, Toronto, Ontario, Canada
- Divisions of Critical Care, Internal Medicine, Emergency Medicine, Psychiatry, Addictions, Family Medicine, and Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Klaiman
- Unity Health Toronto - St. Michael's Hospital, Toronto, Ontario, Canada
- Divisions of Critical Care, Internal Medicine, Emergency Medicine, Psychiatry, Addictions, Family Medicine, and Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Danielle Buell
- Unity Health Toronto - St. Michael's Hospital, Toronto, Ontario, Canada
- Divisions of Critical Care, Internal Medicine, Emergency Medicine, Psychiatry, Addictions, Family Medicine, and Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Johnathan Ailon
- Unity Health Toronto - St. Michael's Hospital, Toronto, Ontario, Canada
- Divisions of Critical Care, Internal Medicine, Emergency Medicine, Psychiatry, Addictions, Family Medicine, and Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Alexander Caudarella
- Unity Health Toronto - St. Michael's Hospital, Toronto, Ontario, Canada
- Divisions of Critical Care, Internal Medicine, Emergency Medicine, Psychiatry, Addictions, Family Medicine, and Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Galo F Ginocchio
- Unity Health Toronto - St. Michael's Hospital, Toronto, Ontario, Canada
| | - Marlene Santos
- Unity Health Toronto - St. Michael's Hospital, Toronto, Ontario, Canada
| | - Gyan Sandhu
- Unity Health Toronto - St. Michael's Hospital, Toronto, Ontario, Canada
| | - Norman Dewhurst
- Unity Health Toronto - St. Michael's Hospital, Toronto, Ontario, Canada
- Divisions of Critical Care, Internal Medicine, Emergency Medicine, Psychiatry, Addictions, Family Medicine, and Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Kelly Sequeira
- Unity Health Toronto - St. Michael's Hospital, Toronto, Ontario, Canada
- Divisions of Critical Care, Internal Medicine, Emergency Medicine, Psychiatry, Addictions, Family Medicine, and Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Karen E A Burns
- Unity Health Toronto - St. Michael's Hospital, Toronto, Ontario, Canada.
- Divisions of Critical Care, Internal Medicine, Emergency Medicine, Psychiatry, Addictions, Family Medicine, and Pharmacy, University of Toronto, Toronto, Ontario, Canada.
- Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada.
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Murphy JA, Curran BM, Gibbons WA, Harnica HM. Adjunctive Phenobarbital for Alcohol Withdrawal Syndrome: A Focused Literature Review. Ann Pharmacother 2021; 55:1515-1524. [PMID: 33678057 DOI: 10.1177/1060028021999821] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To review the literature describing the use of adjunctive phenobarbital in the treatment of severe alcohol withdrawal syndrome (AWS). DATA SOURCES PubMed and EMBASE were searched using the following terms: phenobarbital, adjunct, refractory or treatment resistant, severe or complicated, and alcohol withdrawal delirium or alcohol withdrawal seizures. STUDY SELECTION AND DATA EXTRACTION The search was limited to randomized controlled trials (RCTs) and cohort studies published in English. DATA SYNTHESIS Seven studies were identified in the emergency department (ED; RCT, n = 1; cohort, n = 2), general medicine ward (cohort, n = 1), and intensive care unit (ICU; cohort, n = 3) settings. For all studies set in the ED and general medicine ward and for 1 ICU study, phenobarbital plus symptom-guided benzodiazepine therapy was compared to symptom-guided benzodiazepine monotherapy. The other 2 ICU studies examined adjunctive phenobarbital before and after implementation of a protocol, meaning patients in both arms could have received phenobarbital. Overall risk of bias across all studies was low to moderate. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE The specific role of adjunctive phenobarbital in AWS is not clear because a majority of studies are retrospective cohorts with varying primary outcomes in different patient care settings. CONCLUSIONS In the ED and general medicine ward, phenobarbital demonstrated benzodiazepine-sparing effects. In the ICU, when a protocol guides phenobarbital use, the need for mechanical ventilation may be reduced. Adjunctive phenobarbital was well tolerated. Because of study limitations, it is challenging to provide specific recommendations for adjunctive phenobarbital use in severe AWS.
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Rastegar DA, Jarrell AS, Chen ES. Implementation of a Protocol Using the 5-Item Brief Alcohol Withdrawal Scale for Treatment of Severe Alcohol Withdrawal in Intensive Care Units. J Intensive Care Med 2020; 36:1361-1365. [PMID: 32851920 DOI: 10.1177/0885066620952762] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND There is variation in the treatment of patients with severe alcohol withdrawal and a need for effective protocols. The purpose of this study was to evaluate the implementation of a symptom-triggered benzodiazepine protocol using the 5-item Brief Alcohol Withdrawal Scale (BAWS) for treatment of alcohol withdrawal in intensive care units (ICUs). METHODS This retrospective study included admissions to ICUs of 2 hospitals over 6 months who had an alcohol withdrawal protocol ordered and experienced severe withdrawal. Records were reviewed to collect demographic data, benzodiazepine exposure, duration of treatment, and withdrawal severity. RESULTS The protocol was ordered and implemented in 279 admissions; 48 (17.9%) had severe withdrawal defined as a BAWS of 6 or more. The majority of the 48 patients were from the emergency department (79.2%); mean hospital length of stay was 11.2 days and mean ICU stay 6.6 days; 31.3% required mechanical ventilation. A little more than half were treated only with the protocol (53.2%); 25.0% received additional benzodiazepines, 20.8% dexmedetomidine, 10.4% propofol, 25.0% antipsychotics and 2.0% phenobarbital. CONCLUSION Among ICU patients treated for alcohol withdrawal with a symptom-triggered benzodiazepine protocol using a novel 5-item scale, most did not develop severe withdrawal, and of those who did, approximately half were treated with the protocol alone.
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Affiliation(s)
- Darius A Rastegar
- Division of Addiction Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Andrew S Jarrell
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Edward S Chen
- Division of Pulmonary and Critical Care Medicine, 1466Johns Hopkins University School of Medicine, Baltimore, MD, USA
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