Second, the dexmedetomidine shortage began close to the same time as the initiation of the phenobarbital protocol and continued throughout the study period. This may have increased the benzodiazepine cohort’s relative access to dexmedetomidine. However, since dexmedetomidine is a useful and safe adjunct for treating AWS, the relative absence of dexmedetomidine in the phenobarbital group further supports the safety and efficacy of phenobarbital as a primary Halfway house therapy for AWS. Third, the study’s retrospective nature created the potential for medication crossover, i.e., it was possible for phenobarbital‐treated patients to receive benzodiazepines. Approximately 10% of phenobarbital patients did receive at least one dose of benzodiazepine either concomitantly or after completing the phenobarbital protocol. Alcohol withdrawal syndrome (AWS) is a complication frequently encountered among patients who are chronic alcohol abusers.
Medical
According to Duby et al., the ICU stay was also reduced in the phenobarbital group 16. According to Goodberlet et al., patients who received phenobarbital spent longer in the intensive care unit. The extended ICU stay can be attributed to the study limitations since patients in the phenobarbital arm had severe symptoms, which could explain the prolonged stay in the ICU. In addition, patients were selected only when dexmedetomidine administration was limited in the institute, thereby influencing the choice of sedatives and other pharmacological agents 13. According to Ammar et al., phenobarbital was administered to patients admitted to the surgical intensive care unit for the prevention or worsening of AWS 10. In a study conducted by Oks et al., patients were treated with phenobarbital according to the pharmacological protocol of the medical intensive care unit to manage AWS 11.
Figure 4. Funnel plot of the length of ICU stay for the phenobarbital vs. control group.
Adjunct medications administered included haloperidol, dexmedetomidine, and quetiapine. Fewer adjunct medications administered within the first 2 weeks of hospitalization in phenobarbital‐treated patients can mean multiple things. For example, phenobarbital patients may have been less sedated due to the need for fewer adjunct medications. Overall, this suggests that a phenobarbital protocol may provide a viable alternative to benzodiazepine treatment for AWS and limit side effects, including over‐sedation caused by benzodiazepine treatment.
Phenobarbital-Based Protocol for Alcohol Withdrawal Syndrome in a Medical ICU: Pre-Post Implementation Study
However, AWS can sometimes cause severe and potentially life threatening symptoms, such as delirium and seizures. Rapidly escalating doses of PB over a short period are an effective and safe alternative to BZD in treating AWS in MICUs. Doctors will taper the phenobarbital dosage over time to reduce the risks of phenobarbital withdrawal. These cases will also typically require at least some time in a recovery facility where you can be monitored for signs of seizures or other life threatening symptoms. Kaplan-Meier curves showing the probability of (A) ICU and (B) hospital discharge over time. The blue box represents individual study effects and the black diamond represents the combined result of the studies.
1. Study design, setting, and patient population
Doctors may prescribe phenobarbital to treat AWS and reduce the risk of life threatening complications. We’ll outline alcohol use disorder (AUD) and its relation to AWS cutting back on alcohol symptoms and describe how phenobarbital helps to treat AWS. Alcohol withdrawal syndrome (AWS) can occur when you stop or limit alcohol use after a period of prolonged and heavy use.
- The strengths of our study include the strict inclusion and exclusion criteria focusing on assessing PB-based protocol exclusively on AWS patients in MICU.
- Symptoms are usually mild and may include mild anxiety, headaches, and insomnia.
- Symptoms of AWS begin to manifest eight hours after the last drink and peak 24 to 72 hours later.
- We have identified a major limitation of our analysis as the inclusion of retrospective studies.
On the NIH tool, the case series included in our study received an overall score of 8 out of 9 10. Levels 1 and 2 are the least severe and typically do not require a stay at a recovery facility. Levels 3 and 4 involve more dangerous and require at least a part-time stay at an inpatient facility. Moreover, people who experience alcohol withdrawal seizures are at increased risk of developing recurrent seizures. Phenobarbital has many risks for side effects and interference with other medications. It’s typically not used for long periods of time and only under the supervision of specialized healthcare professionals.
Figure 5. Forest plot of risk of intubation for the phenobarbital vs. control group.
Benzodiazepines are fully effective when GABA is available at the receptor site. A patient with alcohol use disorder has low levels of GABA, causing benzodiazepines to fail to produce the desired response, resulting in resistant alcohol withdrawal syndrome, characterized by hallucinations, seizures, and delirium tremens 3-5. Therefore, other pharmacological agents can be used to control the debilitating symptoms of alcohol withdrawal syndrome. Phenobarbital (a barbiturate) is being increasingly recommended for the treatment of patients with a contraindication to benzodiazepines 4. The effect of phenobarbital is robust because, unlike benzodiazepines, it does not require endogenous GABA 3,6,7.
Figure 2.
The green box represents individual study effects and the black diamond represents the combined result of the studies. The green box represents the individual study effects and the black diamond represents the combined result of the studies. Consuming alcohol while taking phenobarbital can worsen the side effects of phenobarbital. If your doctor feels you may be at risk of seizures during your recovery, they may prescribe phenobarbital. Phenobarbital is a barbiturate medication that works on both GABA and glutamate receptors to help slow brain activity.
- AWS can include seizures, hallucinations, delirium, and/or autonomic instability.
- That said, its use is limited to those with severe symptoms who are undergoing inpatient care.
- Your recovery team will discuss the benefits and risks with you whether they feel it’s necessary for your long-term health.
- Further studies need to be conducted discussing the safety profile and adverse effects of the drug when it comes to the management of alcohol withdrawal syndrome.
- Disagreements were resolved by discussion and by referring to the senior author whenever necessary.
- We conducted a manual search of the references of our included papers in order to ensure that we did not miss any relevant studies.
Data Availability Statement
All content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. Do not disregard or avoid professional medical advice due to content published within Cureus. That said, its use is limited to those with severe symptoms who are undergoing inpatient care. Symptoms are usually mild and may include mild anxiety, headaches, and insomnia.
