Phenobarbital vs. Diazepam-Based Strategies for Treating Severe Alcohol Withdrawal Syndrome in the Emergency...

Phenobarbital is an emerging treatment for alcohol withdrawal syndrome, however scant data exist comparing phenobarbital to benzodiazepines in the emergency department (ED).

To compare phenobarbital to benzodiazepines for treatment of severe alcohol withdrawal syndrome in the ED.

This was a retrospective study of severe alcohol withdrawal syndrome in the ED. The primary outcome measure was the number of drug administrations. Secondary outcomes included ICU admission and respiratory depression.

490 patients met final inclusion criteria; 432 received phenobarbital, 58 received only benzodiazepines. Patients receiving phenobarbital received more diazepam equivalents in the first 6 hours after ED arrival (243 mg vs. 120 mg, difference -109 mg [95% CI: -123 mg to -95 mg]). The number of drug administrations in the first 6 hours after ED arrival was 4 (IQR 3-6) for those who received phenobarbital and 9 (IQR 8-11) for those who received only benzodiazepines (propensity-matched adjusted difference 4, 95% CI 4 to 5). There was no difference in respiratory depression between groups (phenobarbital, 31%; benzodiazepines only, 38% [difference 11.5%, 95% CI: -5.2% to 28.2%]), nor rates of tracheal intubation (13% vs. 14%). Intensive care unit admission was more common in the benzodiazepines-only group (66% vs. 29%; median difference 33% [95% CI: 18.7% to 47.4%]).

For patients with severe alcohol withdrawal syndrome in the ED, phenobarbital administration was associated with fewer drug administrations and ICU admissions compared to a benzodiazepine-only strategy. There was no observed difference in rates of respiratory depression or tracheal intubation.