In this episode, I’ll discuss the biggest risk to using phenobarbital monotherapy for severe alcohol withdrawal.
Phenobarbital is a very effective option for treating severe alcohol withdrawal. A recent retrospective analysis of 3 protocols – one using diazepam alone, one using lorazepam and phenobarbital and one using phenobarbital alone observed similar rates of ICU admission, length of stay, and need for mechanical ventilation between the 3 protocols.
Phenobarbital has beneficial effects on GABA-ergic and glutamatergic receptors, which are the two most important receptor targets in the management of alcohol withdrawal. There have been some excellent write-ups of phenobarbital monotherapy on the Pulmcrit blog here and here
The biggest risk I see with using phenobarbital for alcohol withdrawal is whether or not it is done with good coordination between departments.
Giving benzodiazepines after phenobarbital may increase the risk of respiratory depression.
Therefore there must be good coordination between the ED starting phenobarbital and the floors or ICU who may potentially give benzodiazepines on top of phenobarbital doses. If the floors or ICU are unaware of the prior use of phenobarbital and give large doses of benzodiazepines, they may be caught unprepared for the respiratory depression that could follow.
Members of my Hospital Pharmacy Academy have access to over 75 in-depth, practical trainings including one on the treatment of severe alcohol withdrawal. To get immediate access to these and more resources to help you in your practice go to pharmacyjoe.com/academy.
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