Practice Patterns of Phenobarbital Use in Severe Alcohol withdrawal Syndrome
CCCF ePoster library. Buell D. Nov 7, 2018; 233351; 11
Dr. Danielle Buell
Dr. Danielle Buell
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Introduction Treatment of acute alcohol withdrawal syndrome (AAWS) with symptom-triggered benzodiazepine therapy is well described1,2. However, the optimal management of patients with refractory or severe AAWS (sAAWS) is unclear. Three small randomized control trials suggest that intravenous phenobarbital may be an effective adjuvant therapy for the treatment of sAAWS3-5. Despite this, several factors likely limit its use in clinical practice.

Objectives To characterize current practice patterns in treatment of sAAWS and assess the current attitudes and knowledge around the use of phenobarbital for patients with sAAWS at centers specializing in inner-city healthcare.

Methods We conducted a cross-sectional multi-center, interdisciplinary, self-administered paper and electronic survey6 of general internists, intensivists, psychiatrists and emergency medicine physicians at St. Michael’s (ON) and St. Paul’s Hospital (BC).

Results We received 118/194 (61% response rate) completed questionnaires. Most respondents were male (62%), older than 40 (76%), in practice for a mean of 14 years, with 66% of their time spent in clinical practice. Only 3 respondents were addiction specialists, 2 of whom used phenobarbital in their practice. Respondents managed an average of 32 cases of AAWS in a 6-month period, of which 7 (22%) were severe.

Respondents defined severe alcohol withdrawal by the presence of seizures (80%), hallucinations (60%) and a CIWA score > 15 after 60mg of diazepam (56%). Most respondents (60.4%) did not use phenobarbital in their practice. Of those that used phenobarbital, 58% considered using it as an adjuvant treatment if patients were refractory to symptom-based benzodiazepine therapy, whereas others waited until seizures developed (10%) or ICU admission was warranted (18%). Intravenous administration was twice as likely to be used as oral phenobarbital. Most respondents (58%) did not know the peak onset of phenobarbital activity, 33% were unfamiliar with the side effects, and 42% were uncomfortable with its contraindications. Only 6% of respondents were aware of the evidence supporting phenobarbital use. Haloperidol and clonidine were the 2 most commonly used adjuvant treatments used to treat sAAWS. Although 59% of respondents were uncomfortable using phenobarbital in their practice, 85% were either comfortable or neutral with enrolling patients in a trial to investigate the use of phenobarbital for patients with sAAWS.

Conclusion Our results suggest that despite seeing a high volume of sAAWS, there is considerable stated practice variation in how clinicians treat patients with sAAWS. Our results highlight both a lack of awareness regarding the current evidence supporting phenobarbital use for sAAWS and discomfort with its use in practice. Those that used phenobarbital, reported using the IV preparation and administering it early in treatment. Most respondents felt that greater evidence was needed, and expressed equipoise for enrolling patients with sAAWS in a trial evaluating IV phenobarbital as an adjuvant therapy to symptom-triggered benzodiazepine therapy.


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