In this episode, I’ll discuss whether phenobarbital offers a clinically meaningful advantage over benzodiazepines for alcohol withdrawal in the ED.
Some clinicians prefer phenobarbital over benzodiazepines for alcohol withdrawal patients presenting to the emergency department. Like benzos, phenobarbital targets gamma-aminobutyric acid (GABA) receptors in the central nervous system. However phenobarbital has a 2nd mechanism applicable to alcohol withdrawal and that is the targeting of glutamate receptors. This is potentially desirable because alcohol withdrawal is a result of both the lack of GABA activity AND over stimulation of glutamate receptors.
At a recent American College of Emergency Physicians meeting a group of authors presented in abstract form a systematic review and meta-analysis of Phenobarbital vs Benzodiazepines for Treatment of Alcohol Withdrawal in the Emergency Department.
The authors included 8 studies in their review, two of which were double-blinded randomized controlled trials and the rest were retrospective cohort studies. Just over 1500 patients were represented in the studies. The clinically relevant outcomes analyzed were ICU admissions, hospital admissions, ED re-admissions, and adverse events in the ED.
For all of the outcomes analyzed, the 95% confidence interval for the relative risk between phenobarbital and benzodiazepines included 1, meaning there was no difference present between the two classes of medications.
The authors conlcuded:
The current literature base suggests that, compared to treatment with benzodiazepine alone, treatment with phenobarbital does not significantly reduce ICU admissions, hospital admissions, ED re-admissions, or adverse events in ED patients with AWS.
Advocates of benzodiazepines can point to this meta-analysis and say “If there is no difference, why not continue to use benzos which we have the most clinical experience with?”
While advocates of phenobarbital can point to this meta-analysis and say “Even if there are no differences in outcomes identified yet in the literature, since there is a theoretical advantage to phenobarbital why not use it since it appears at least as good as benzos?”
My preference is still for benzodiazepines in most patients using phenobarbital in those that appear resistant to aggressive doses of benzos.
Members of the Hospital Pharmacy Academy have access to practical training on the treatment of severe alcohol withdrawal from a pharmacists point of view, including how to use phenobarbital for this indication. From practical training on clinical topics to support from myself and other members in the forums, the Hospital Pharmacy Academy has all you need to take your skills to the next level in one place. To get instant access go to pharmacyjoe.com/academy.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.