1146: EARLY VERSUS LATE ADMINISTRATION OF PHENOBARBITAL IN ACUTE ALCOHOL WITHDRAWAL

Abstract

Introduction: Alcohol withdrawal syndrome (AWS) is the leading cause of mortality in patients with alcohol use disorder due to complications like seizures and delirium tremens. The current standard of care for management is Clinical Institute Withdrawal Assessment (CIWA)-guided benzodiazepine administration. Phenobarbital in addition to a CIWA protocol is shown to be a safe adjuvant in patients with AWS but optimal timing has not been established. The purpose of this study is to evaluate the effects of early vs. late vs. no administration of phenobarbital for the management of AWS. Methods: A retrospective chart review of adult patients in the emergency department (ED) for AWS who received a benzodiazepine or phenobarbital. Exclusion criteria included: pregnancy, study drug use for an indication other than AWS, left against medical advice/discharged within 48 hours, and primary seizure disorder. Study groups were as follows: early (phenobarbital before receiving >30mg of lorazepam equivalents), late (phenobarbital after receiving >30mg of lorazepam equivalents), and none. The primary outcome was cumulative dose of benzodiazepine per day. Secondary outcomes included ICU admissions, reduction of CIWA score from baseline, need for adjuvant agents, and safety outcomes. Results: Seventy-five patients were included in this study (29 early group, 20 late group, 26 none group). Early phenobarbital patients received less benzodiazepines compared to the late and none groups (11.88 mg vs. 36.21 mg vs. 21.29 mg). Average change from baseline CIWA was greater in the early group than in the late and none groups (12.94 vs. 7.89 vs. 5.25). Early phenobarbital compared to late resulted in lower ICU admissions (67.7% vs. 88.0%) and less need for adjuvant therapy (34.3% vs. 64%). More intubations were seen in the early and late groups compared to the no phenobarbital group, but all intubations were due to severe AWS requiring continuous sedation. Conclusions: Phenobarbital led to decreased benzodiazepine requirements, greater change from baseline CIWA score, and less need for adjuvant therapy without an increased risk of adverse effects. Early phenobarbital administration was associated with decreased benzodiazepine requirements, greater change from baseline CIWA score, less ICU admissions, and less need for adjuvant therapy.