Phenobarbital for Alcohol Withdrawal: Difference between revisions
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# Unique among the barbiturates, PB | # Unique among the barbiturates, PB is an ''anti-consultant''. | ||
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Revision as of 21:54, 28 August 2019
Phenobarbital is a non-competitive gamma-Aminobutyric acid (GABA) agonist which is an equally effective and safe alternative to benzodiazepines (BZD) for the treatment of alcohol withdrawal syndrome (AWS).[1] Though its use for AWS has waned and consequently many clinicians are now unfamiliar with this regimen, PB has both mechanistic and pharmacokinetic properties which make it more suitable for outpatient monotherapy than BZD.
IV/IM titrated PB is the first-line outpatient medication used for treatment of AWS at the Yukon-Kuskokwim Delta Regional Hospital. Its use is favored because substantial experience has shown that it is effective, it minimizes return visits, and it eliminates the need to dispense abuse-prone medications (i.e. BZD) to abuse-prone patients while in the midst of a substance abuse crisis. Indeed, minimizing high-risk dispensing of abuse-prone medication is important for improving the health of our community.
Evidence of Effectiveness and Safety
A 2016 systematic review by Mo et al. in the Journal of Critical Care[1] concluded that "barbiturates alone or in combination with BZDs are at least as effective as BZDs in the treatment of AWS. Furthermore, barbiturates appear to have acceptable tolerability and safety profiles, which were similar to those of BZDs in patients with AWS." This review included three randomized controlled trials (RCT's) and four observational studies. While this review firmly establishes PB's similar pharmacological effectiveness compared to BZD's, only one of the included studies (an RCT by Hendey et al.[2]) focused solely upon outpatient treatment. Though its sample size was not large (25 in PB group, 19 in BZD group), Hendey et al. did report statistically nonsignificant trends toward better outcomes in the PB group.
Pharmacology
The following are the important properties of PB with regard to outpatient treatment of AWS.
Drug Class
Chemical Class
PB belongs to the chemical class barbiturate.
Clinical Class
- Like all barbiturates, PB is a sedative/hypnotic.
- Unique among the barbiturates, PB is an anti-consultant.
Mechanism of Action
Dosing
Distribution
Elimination
Adverse Effects
Cautions
Contraindications
Authors
Andrew W. Swartz, MD
?
References
- ↑ 1.0 1.1 Mo Y, Thomas MC, Karras GE. Barbiturates for the treatment of alcohol withdrawal syndrome: A systematic review of clinical trials. J Crit Care. 2016;32:101-107. doi:10.1016/j.jcrc.2015.11.022
- ↑ Hendey GW, Dery RA, Barnes RL, Snowden B, Mentler P. A prospective, randomized, trial of phenobarbital versus benzodiazepines for acute alcohol withdrawal. Am J Emerg Med. 2011;29(4):382-385. doi:10.1016/j.ajem.2009.10.010
