{"title":"Future Considerations in Response to \"Adjunctive Phenobarbital for Alcohol Withdrawal Syndrome: A Focused Literature Review\".","authors":"Rose Alwardi, Tony Rondinella, Andrea Quinn","doi":"10.1177/87551225211042957","DOIUrl":null,"url":null,"abstract":"To the Editor: It is crucial to consider all limitations demonstrated throughout previous trials in order to develop clinically reliable recommendations from published evidence. Murphy et al summarized 3 main limitations of inconsistency with use of phenobarbital for alcohol withdrawal: inconsistent dosing strategies, varying primary outcomes, and nonstandardized utilization of assessment scales.1-3 A retrospective observational cohort study was conducted at our organization, a 425-bed nonteaching community hospital, with intent to evaluate the adjunctive use of phenobarbital in alcohol withdrawal syndrome (AWS). Patients admitted from August to December of 2020 were divided 1:1 based on receipt of phenobarbital in addition to a Clinical Institute Withdrawal Assessment (CIWA)-driven benzodiazepine protocol versus a CIWA-driven benzodiazepine protocol alone. The primary endpoint was total length of hospital stay with secondary endpoints assessing total intensive care unit (ICU) length of stay, total dosage of benzodiazepine (based on diazepam equivalents), and total dosage of phenobarbital utilization during admission. A total of 60 patients were included in the analysis with 30 in each group. Patients were well matched in terms of history of withdrawal seizures and liver disease. The phenobarbital group had a higher total CIWA score compared with the cohort group (289.8 vs 124.6), suggestive of more severely presenting alcoholics in the former group. Patients in the phenobarbital group had an increased length of hospital stay compared with the cohort group (4.3 vs 2.4 days). Patients receiving phenobarbital also had a prolonged ICU length of stay (3.58 vs 0.27 days) and required higher total benzodiazepine utilization (194.5 vs 79.9 mg). On further investigation, there was a disproportionate amount of patients admitted to the ICU in the phenobarbital group compared with the cohort (20/30 vs 3/30 patients). Average phenobarbital daily dose was approximately half of that reported in previous studies at 57.8 mg/ day.4,5 Patients presenting with more severe withdrawal were more likely to receive phenobarbital, making it difficult to assess the true impact of therapy due to selection bias. Eighty percent of phenobarbital orders were made by one specific provider introducing prescriber bias as another potential limitation. Universally similar to previous studies assessing phenobarbital in AWS, there was no consistent dose or protocol utilized at our organization. Although our small study did not suggest clinical benefit with adjunctive phenobarbital utilization, commonality with other studies is found in the limitations and biases. Considering the amount of positive data present, phenobarbital likely has a place in AWS therapy. Recommendations for when, how, and in whom to initiate phenobarbital relies on consistent and repeatable protocolized evaluations.","PeriodicalId":16796,"journal":{"name":"Journal of Pharmacy Technology","volume":"37 6","pages":"320-321"},"PeriodicalIF":1.1000,"publicationDate":"2021-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8592240/pdf/10.1177_87551225211042957.pdf","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Journal of Pharmacy Technology","FirstCategoryId":"1085","ListUrlMain":"https://doi.org/10.1177/87551225211042957","RegionNum":0,"RegionCategory":null,"ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"2021/9/22 0:00:00","PubModel":"Epub","JCR":"Q4","JCRName":"PHARMACOLOGY & PHARMACY","Score":null,"Total":0}
引用次数: 0
Abstract
To the Editor: It is crucial to consider all limitations demonstrated throughout previous trials in order to develop clinically reliable recommendations from published evidence. Murphy et al summarized 3 main limitations of inconsistency with use of phenobarbital for alcohol withdrawal: inconsistent dosing strategies, varying primary outcomes, and nonstandardized utilization of assessment scales.1-3 A retrospective observational cohort study was conducted at our organization, a 425-bed nonteaching community hospital, with intent to evaluate the adjunctive use of phenobarbital in alcohol withdrawal syndrome (AWS). Patients admitted from August to December of 2020 were divided 1:1 based on receipt of phenobarbital in addition to a Clinical Institute Withdrawal Assessment (CIWA)-driven benzodiazepine protocol versus a CIWA-driven benzodiazepine protocol alone. The primary endpoint was total length of hospital stay with secondary endpoints assessing total intensive care unit (ICU) length of stay, total dosage of benzodiazepine (based on diazepam equivalents), and total dosage of phenobarbital utilization during admission. A total of 60 patients were included in the analysis with 30 in each group. Patients were well matched in terms of history of withdrawal seizures and liver disease. The phenobarbital group had a higher total CIWA score compared with the cohort group (289.8 vs 124.6), suggestive of more severely presenting alcoholics in the former group. Patients in the phenobarbital group had an increased length of hospital stay compared with the cohort group (4.3 vs 2.4 days). Patients receiving phenobarbital also had a prolonged ICU length of stay (3.58 vs 0.27 days) and required higher total benzodiazepine utilization (194.5 vs 79.9 mg). On further investigation, there was a disproportionate amount of patients admitted to the ICU in the phenobarbital group compared with the cohort (20/30 vs 3/30 patients). Average phenobarbital daily dose was approximately half of that reported in previous studies at 57.8 mg/ day.4,5 Patients presenting with more severe withdrawal were more likely to receive phenobarbital, making it difficult to assess the true impact of therapy due to selection bias. Eighty percent of phenobarbital orders were made by one specific provider introducing prescriber bias as another potential limitation. Universally similar to previous studies assessing phenobarbital in AWS, there was no consistent dose or protocol utilized at our organization. Although our small study did not suggest clinical benefit with adjunctive phenobarbital utilization, commonality with other studies is found in the limitations and biases. Considering the amount of positive data present, phenobarbital likely has a place in AWS therapy. Recommendations for when, how, and in whom to initiate phenobarbital relies on consistent and repeatable protocolized evaluations.
期刊介绍:
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