(123) Phenobarbital Versus Benzodiazepines for the Treatment of Severe Alcohol Withdrawal

Sunday, January 21, 2024

9:45 AM – 10:45 AM MT

Location: Connections Central - RST 16

First Author(s)

Katherine M. Kessel, PharmD, (she/her/hers)

PGY2 Critical Care Pharmacy Resident
Nebraska Medicine - Nebraska Medical Center
Omaha, NE

Co-Author(s)

LO

Logan Olson, PharmD, BCCCP

PGY2 Critical Care Pharmacy Residency Program Director, Inpatient Critical Care Pharmacist
Nebraska Medicine - Nebraska Medical Center, United States
DK

Derek Kruse, MD

Assistant Professor, Pulmonary, Critical Care & Sleep Medicine Division
University of Nebraska Medical Center, United States
EL

Elizabeth Lyden, MS

Associate Director, Center for Collaboration on Research, Design and Analysis
University of Nebraska Medical Center, United States
KW

Kelsey Whiston, PharmD, BCCCP

Inpatient Critical Care Pharmacist
Nebraska Medicine - Nebraska Medical Center, United States
MB

Mindy Blodgett, APRN

Nurse Practitioner, Department of Critical Care Medicine
Nebraska Medicine - Nebraska Medical Center, United States
AB

Alena Balasanova, MD, FAPA

Director, Addiction Psychiatry Education, Associate Professor, Department of Psychiatry
University of Nebraska Medical Center, United States

Introduction: Severe alcohol withdrawal syndrome (SAWS) can precipitate hallucinations, delirium tremens (DT), seizures, and death. Scheduled phenobarbital may offer advantages over symptom-triggered benzodiazepines for SAWS regarding hospital length of stay (LOS), intensive care unit (ICU) LOS, and incidence of mechanical ventilation, but its role in therapy has not been fully elucidated.

Methods: This retrospective cohort study compared patients admitted to the intensive care unit (ICU) or progressive care unit who received scheduled phenobarbital or benzodiazepines for management of SAWS between July 2018 to July 2022. Patients were included if they had a history of DT or seizures, Clinical Institute Withdrawal Assessment of Alcohol (CIWA-AR) > 15, or Prediction of Alcohol Withdrawal Severity Scale (PAWSS) ≥  4. The primary outcome was hospital LOS. Secondary outcomes included ICU or progressive care LOS, incidence of adjunctive pharmacotherapy, and incidence and duration of mechanical ventilation.

Results: Data from 126 phenobarbital and 98 benzodiazepine encounters was analyzed. Inclusion criteria met were history of seizures (78.1%), CIWA-Ar > 15 (68.3%), history of DT (61.6%), and PAWSS ≥ 4 (16.5%). Patients who received phenobarbital had a significantly shorter hospital LOS compared to patients who received benzodiazepines (median [IQR], 2.8 [2.5-3.5] vs. 4.7 [2.9-6.7] days; p < 0.0001). Those who received phenobarbital also had shorter ICU/progressive LOS (median [IQR], 0.7 [0.6-0.9] vs. 1.3 [0.8-2.2] days; p < 0.0001), and a lower incidence of dexmedetomidine (6 [4.8%] vs. 53 [54.1%]; p < 0.0001) and antipsychotic initiation (7 [5.6%] vs. 36 [36.7%]); p < 0.0001). One (0.8%) patient in the phenobarbital group compared to 6 (6.1%) patients in the benzodiazepine group was mechanically ventilated (p = 0.045), but there was no difference in duration of new mechanical ventilation (median [IQR], 1.2 vs. 1.6 [1-3] days; p = 1.00).

Conclusions: Scheduled phenobarbital was associated with a decrease in hospital LOS, ICU/progressive LOS, initiation of adjunctive pharmacotherapy, and incidence of new mechanical ventilation compared to benzodiazepines for SAWS.