SHM's Clinical Quick Talks-Benzodiazepines Versus Phenobarbital in the Treatment of Alcohol Withdrawal Syndrome

Pdf Summary

The document provides a comparative analysis of benzodiazepines (BZDs) and phenobarbital (PB) in managing Alcohol Withdrawal Syndrome (AWS). AWS has increased notably in emergency department (ED) visits post-COVID-19, making alcohol the leading cause in substance-related emergencies, surpassing opioids and cannabis. Up to 50% of individuals with Alcohol Use Disorder (AUD) experience AWS, with 5% potentially developing life-threatening delirium tremens.<br /><br />The document outlines the pathophysiology of AWS, pointing to altered GABAergic and glutamatergic activity in the brain as the primary cause. BZDs, which enhance GABA-A receptor activity, have traditionally been the standard treatment for AWS. However, PB offers several advantages by enhancing GABAergic inhibition and reducing NMDA receptor-mediated glutamate excitation, making it useful in severe, refractory cases, or those involving cirrhosis. <br /><br />Drug efficacy scales like the Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) and the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) are crucial for assessing AWS severity and guiding treatment. The text highlights the potential benefits of PB, including the reduction of hospital and ICU stays and its efficacy in situations of BZD resistance. <br /><br />Despite the advantages, PB requires careful dosing and monitoring due to limited familiarity in some settings and the necessity of precise titration. There's a notable gap in Randomized Controlled Trials directly comparing PB and BZDs, which warrants further research for protocol standardization and exploring long-term outcomes. <br /><br />Lastly, the document underscores the need for high-quality studies to explore PB and BZDs' long-term effectiveness, particularly in high-risk patients and in frameworks like the ED or ICU.

Asset Subtitle

Lindsey Davis, Alexander Merk

Keywords

Alcohol Withdrawal Syndrome

benzodiazepines

phenobarbital

emergency department

GABAergic activity

glutamatergic activity

CIWA-Ar

PAWSS

delirium tremens

Randomized Controlled Trials