Benzodiazepine medications have long been the standard of care for patients presenting to emergency departments (EDs) for acute treatment of alcohol withdrawal syndrome (AWS). With many EDs not having ready access to hospital admission or detoxification transfer of patients, safe and effective acute AWS management that allows patients to be discharged the same day as presentation would be advantageous. This study was conducted in a rural Canadian hospital; it compared ED administration of a front-loaded phenobarbital regimen versus a symptom-triggered benzodiazepine regimen for AWS. Outcomes were ED length of stay and need for hospital admission.
- Eighty-three patients were treated during 185 visits for AWS.
- The front-loaded phenobarbital regimen employed was relatively rapid and high-dose (up to 20mg/kg during the same-day treatment).
- Median length of stay in the ED for both regimens was 4.4 hours.
- After adjusting for confounders, hospital admission odds were 71% lower with the phenobarbital regimen.
- The authors report no “significant” adverse events related to receipt of phenobarbital.
Comments: Length of stay for most patients who present for acute AWS management can range 3–7 days. In this study, front-loaded phenobarbital for the treatment of AWS appears to be an effective strategy to prevent the escalation of withdrawal symptoms and the need for hospital admission. Notably this study did not compare front-loaded phenobarbital to front-loaded benzodiazepines. Rigorous clinical trial research is needed to compare the safety and efficacy of phenobarbital versus benzodiazepine medications for the treatment of AWS.
Melissa B. Weimer, DO, MCR
Reference: 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.