In this episode, I’ll discuss phenobarbital vs. benzodiazepine-based pathways for alcohol withdrawal syndrome in the ICU.
Considerable research has been done comparing phenobarbital with benzodiazepines for alcohol withdrawal syndrome in critically ill adult patients. A group of authors have synthesized this research in a systematic review and meta-analysis published in Pharmacotherapy.
Sixteen comparative studies of adults admitted or transferred to an intensive care unit (ICU) with AWS and treated with phenobarbital-based versus benzodiazepine-based pathways were included in the analysis.
The authors found that phenobarbital-based pathways were not associated with significantly different odds of intubation or hospital length of stay when compared with benzodiazepine-based pathways. ICU length of stay was significantly shorter with phenobarbital-based pathways by an average of 0.6 days. When exploratory subgroup analyses was conducted, the authors found front-loaded, protocolized phenobarbital-first pathways to be associated with both lower intubation and shorter hospital length of stay. However, the certainty of evidence for this finding was very low.
The authors concluded:
Although evidence remains very low certainty, these findings suggest that phenobarbital’s role in ICU AWS may be pathway dependent. Front-loaded, protocolized phenobarbital-first pathways may be associated with favorable outcomes in exploratory analyses, but these findings should be considered hypothesis-generating and require confirmation in prospective randomized trials.
Hopefully these findings will be used to set the direction for future research so that the role of phenobarbital in this high-risk and difficult to manage population is better defined.
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