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Lee CM, Dillon DG, Tahir PM, Murphy CE. Phenobarbital treatment of alcohol withdrawal in the emergency department: A systematic review and meta-analysis. Acad Emerg Med 2024; 31:515-524. [PMID: 37923363 PMCID: PMC11065966 DOI: 10.1111/acem.14825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 10/14/2023] [Accepted: 10/17/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE Despite frequent treatment of alcohol withdrawal syndrome (AWS) in the emergency department (ED), evidence for phenobarbital (PB) as an ED alternative therapy is mixed. We conducted a systematic review and meta-analysis comparing safety and efficacy of PB to benzodiazepines (BZDs) for treatment of AWS in the ED. METHODS We searched articles and references published in English in PubMed, Web of Science, and Embase from inception through May 2022. We included randomized trials and cohort studies comparing treatment with PB to BZD controls and excluded studies focused on non-AWS conditions. Review was conducted by two blinded investigators and a third author; eight of 59 (13.6%) abstracts met inclusion criteria for review and meta-analysis using a random-effects model. Treatment superiority was evaluated through utilization, pharmacologic, and clinical outcomes. Primary outcomes for meta-analysis were the proportion of patients (1) admitted to the intensive care unit (ICU), (2) admitted to the hospital, (3) readmitted to the ED after discharge, and (4) who experienced adverse events. RESULTS Eight studies (two randomized controlled trials, six retrospective cohorts) comprised data from 1507 patients in 2012 treatment encounters for AWS. All studies were included in meta-analysis for adverse events, seven for hospital admission, five for ICU admission, and three for readmission to the ED after discharge. Overall methodological quality was low-moderate, risk of bias moderate-high, and statistical heterogeneity moderate. Pooled relative risk of ICU admission for those treated with PB versus BZD was 0.92 (95% confidence interval [CI] 0.54-1.55). Risk for admission to the hospital was 0.98 (95% CI 0.89-1.07) and for any adverse event was 1.1 (95% CI 0.78-1.57); heterogeneity prevented meta-analysis for ED readmission. CONCLUSIONS The current literature base does not show that treatment with PB significantly reduces ICU admissions, hospital admissions, ED readmissions, or adverse events in ED patients with AWS compared with BZDs alone.
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Affiliation(s)
- Carmen M Lee
- Department of Emergency Medicine, Highland Hospital, Alameda Health System, Oakland, California
| | - David G Dillon
- Emergency Medicine at the University of California, Davis School of Medicine, Sacramento, California
| | - Peggy M Tahir
- Research and Copyright Librarian at the University of California, San Francisco Library, San Francisco, California
| | - Charles E Murphy
- Associate Physician Diplomate in Emergency Medicine at the University of California, San Francisco School of Medicine, San Francisco, California
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Punia K, Scott W, Manuja K, Campbell K, Balodis IM, MacKillop J. SAEM GRACE: Phenobarbital for alcohol withdrawal management in the emergency department: A systematic review of direct evidence. Acad Emerg Med 2024; 31:481-492. [PMID: 37589203 DOI: 10.1111/acem.14788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 06/19/2023] [Accepted: 07/02/2023] [Indexed: 08/18/2023]
Abstract
OBJECTIVES Alcohol withdrawal syndrome (AWS) is a commonly presenting condition in the emergency department (ED) and can have severe complications, including mortality. Benzodiazepines are first-line medications for treating AWS but may be unavailable or insufficient. This systematic review evaluates the direct evidence assessing the utility of phenobarbital for treating AWS in the ED. METHODS A systematic search was conducted and designed according to the patient-intervention-comparator-outcome (PICO) question: (P) adults (≥18 years old) presenting to the ED with alcohol withdrawal; (I) phenobarbital (including adjunctive); (C) benzodiazepines or no intervention; and (O) AWS complications, admission to a monitored setting, control of symptoms, adverse effects, and adjunctive medications. Two reviewers independently assessed articles for inclusion and conducted risk of bias assessments for included studies. RESULTS From 70 potentially relevant articles, seven studies met inclusion criteria: three retrospective cohort studies, two retrospective chart reviews, and two randomized controlled trials (RCTs), one examining phenobarbital monotherapy and one examining adjunctive phenobarbital. Across the retrospective cohort studies, treatment of AWS with phenobarbital resulted in lower odds of a subsequent ED visit. The retrospective chart reviews indicated that phenobarbital was associated with higher discharge rate compared to benzodiazepine-only treatments. For the two RCTs, phenobarbital did not differ significantly from benzodiazepine for most outcomes, although concomitant treatment with phenobarbital was associated with lower benzodiazepine use and intensive care unit admission. The heterogeneous designs and small number of studies prevented quantitative synthesis. CONCLUSIONS Relatively few studies provide direct evidence on the utility of phenobarbital for AWS in the ED, but the evidence that exists generally suggests that it is a reasonable and appropriate approach. Additional RCTs and other methodologically rigorous investigations are needed for more definitive direct evidence.
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Affiliation(s)
- Kiran Punia
- Department of Psychology, Neuroscience, and Behaviour, McMaster University, Ontario, Hamilton, Canada
- Peter Boris Centre for Addictions Research, St. Joseph's Healthcare Hamilton/McMaster University, Hamilton, Ontario, Canada
| | - William Scott
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Kriti Manuja
- Peter Boris Centre for Addictions Research, St. Joseph's Healthcare Hamilton/McMaster University, Hamilton, Ontario, Canada
| | | | - Iris M Balodis
- Peter Boris Centre for Addictions Research, St. Joseph's Healthcare Hamilton/McMaster University, Hamilton, Ontario, Canada
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
- Michael G. DeGroote Centre for Medicinal Cannabis Research (CMCR), McMaster University, Hamilton, Ontario, Canada
| | - James MacKillop
- Peter Boris Centre for Addictions Research, St. Joseph's Healthcare Hamilton/McMaster University, Hamilton, Ontario, Canada
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
- Michael G. DeGroote Centre for Medicinal Cannabis Research (CMCR), McMaster University, Hamilton, Ontario, Canada
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Qu L, Ma XP, Simayi A, Wang XL, Xu GP. Comparative efficacy of various pharmacologic treatments for alcohol withdrawal syndrome: a systematic review and network meta-analysis. Int Clin Psychopharmacol 2024; 39:148-162. [PMID: 38170803 DOI: 10.1097/yic.0000000000000526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
This study was to compare multiple classes of medications and medication combinations to find alternatives or additives for patients not applicable to benzodiazepines (BZDs). We performed a network meta-analysis to assess the comparative effect of 11 pharmacologic treatments in patients with alcohol withdrawal syndrome. Forty-one studies were included, comprising a total sample size of 4187 participants. The pooled results from the randomized controlled trials showed that there was no significant difference in the Clinical Institute Withdrawal Assessment-Alcohol, revised (CIWA-Ar) reduction with other medications or medication combinations compared to BZDs. Compared to BZDs, the mean difference in ICU length of stay of anticonvulsants + BZDs was -1.71 days (95% CI = -2.82, -0.59). Efficacy rankings from cohort studies showed that anticonvulsant + BZDs were superior to other treatments in reducing CIWA-Ar scores and reducing the length of stay in the ICU. Synthesis results from randomized controlled trials indicate that there are currently no data suggesting that other medications or medication combinations can fully replace BZDs. However, synthetic results from observational studies have shown that BZDs are effective in the context of adjuvant anticonvulsant therapy, particularly with early use of gabapentin in combination with BZDs in the treatment of alcohol withdrawal syndrome, which represents a promising treatment option.
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Affiliation(s)
- Li Qu
- Department of Anesthesia, People's Hospital of Xinjiang Uygur Autonomous Region, Xinjiang, China
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To DC, Steel TL, Carey KA, Joyce CJ, Salisbury-Afshar EM, Edelson DP, Mayampurath A, Churpek MM, Afshar M. Alcohol Withdrawal Severity Measures for Identifying Patients Requiring High-Intensity Care. Crit Care Explor 2024; 6:e1066. [PMID: 38505174 PMCID: PMC10950191 DOI: 10.1097/cce.0000000000001066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024] Open
Abstract
OBJECTIVES Alcohol withdrawal syndrome (AWS) may progress to require high-intensity care. Approaches to identify hospitalized patients with AWS who received higher level of care have not been previously examined. This study aimed to examine the utility of Clinical Institute Withdrawal Assessment Alcohol Revised (CIWA-Ar) for alcohol scale scores and medication doses for alcohol withdrawal management in identifying patients who received high-intensity care. DESIGN A multicenter observational cohort study of hospitalized adults with alcohol withdrawal. SETTING University of Chicago Medical Center and University of Wisconsin Hospital. PATIENTS Inpatient encounters between November 2008 and February 2022 with a CIWA-Ar score greater than 0 and benzodiazepine or barbiturate administered within the first 24 hours. The primary composite outcome was patients who progressed to high-intensity care (intermediate care or ICU). INTERVENTIONS None. MAIN RESULTS Among the 8742 patients included in the study, 37.5% (n = 3280) progressed to high-intensity care. The odds ratio for the composite outcome increased above 1.0 when the CIWA-Ar score was 24. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) at this threshold were 0.12 (95% CI, 0.11-0.13), 0.95 (95% CI, 0.94-0.95), 0.58 (95% CI, 0.54-0.61), and 0.64 (95% CI, 0.63-0.65), respectively. The OR increased above 1.0 at a 24-hour lorazepam milligram equivalent dose cutoff of 15 mg. The sensitivity, specificity, PPV, and NPV at this threshold were 0.16 (95% CI, 0.14-0.17), 0.96 (95% CI, 0.95-0.96), 0.68 (95% CI, 0.65-0.72), and 0.65 (95% CI, 0.64-0.66), respectively. CONCLUSIONS Neither CIWA-Ar scores nor medication dose cutoff points were effective measures for identifying patients with alcohol withdrawal who received high-intensity care. Research studies for examining outcomes in patients who deteriorate with AWS will require better methods for cohort identification.
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Affiliation(s)
- Daniel C To
- Department of Medicine, University of Wisconsin-Madison, Madison, WI
| | - Tessa L Steel
- Department of Medicine, University of Washington, Seattle, WA
| | - Kyle A Carey
- Department of Medicine, University of Chicago, Chicago, IL
| | - Cara J Joyce
- Department of Public Health Sciences, Loyola University Chicago, Maywood, IL
| | | | - Dana P Edelson
- Department of Medicine, University of Chicago, Chicago, IL
| | - Anoop Mayampurath
- Department of Medicine, University of Wisconsin-Madison, Madison, WI
- Department of Bioinformatics and Medical Informatics, University of Wisconsin-Madison, Madison, WI
| | - Matthew M Churpek
- Department of Medicine, University of Wisconsin-Madison, Madison, WI
- Department of Bioinformatics and Medical Informatics, University of Wisconsin-Madison, Madison, WI
| | - Majid Afshar
- Department of Medicine, University of Wisconsin-Madison, Madison, WI
- Department of Bioinformatics and Medical Informatics, University of Wisconsin-Madison, Madison, WI
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Kessel KM, Olson LM, Kruse DA, Lyden ER, Whiston KE, Blodgett MM, Balasanova AA. Phenobarbital Versus Benzodiazepines for the Treatment of Severe Alcohol Withdrawal. Ann Pharmacother 2024:10600280231221241. [PMID: 38247044 DOI: 10.1177/10600280231221241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND Phenobarbital may offer advantages over benzodiazepines for severe alcohol withdrawal syndrome (SAWS), but its impact on clinical outcomes has not been fully elucidated. OBJECTIVE The purpose of this study was to determine the clinical impact of phenobarbital versus benzodiazepines for SAWS. METHODS This retrospective cohort study compared phenobarbital to benzodiazepines for the management of SAWS for patients admitted to progressive or intensive care units (ICUs) between July 2018 and July 2022. Patients included had a history of delirium tremens (DT) or seizures, Clinical Institute Withdrawal Assessment of Alcohol-Revised (CIWA-Ar) >15, or Prediction of Alcohol Withdrawal Severity Scale (PAWSS) score ≥4. The primary outcome was hospital length of stay (LOS). Secondary outcomes included progressive or ICU LOS, incidence of adjunctive pharmacotherapy, and incidence/duration of mechanical ventilation. RESULTS The final analysis included 126 phenobarbital and 98 benzodiazepine encounters. Patients treated with phenobarbital had shorter median hospital LOS versus those treated with benzodiazepines (2.8 vs 4.7 days; P < 0.0001); a finding corroborated by multivariable analysis. The phenobarbital group also had shorter median progressive/ICU LOS (0.7 vs 1.3 days; P < 0.0001), and lower incidence of dexmedetomidine (P < 0.0001) and antipsychotic initiation (P < 0.0001). Fewer patients in the phenobarbital group compared to the benzodiazepine group received new mechanical ventilation (P = 0.045), but median duration was similar (1.2 vs 1.6 days; P = 1.00). CONCLUSION AND RELEVANCE Scheduled phenobarbital was associated with decreased hospital LOS compared to benzodiazepines for SAWS. This was the first study to compare outcomes of fixed-dose, nonoverlapping phenobarbital to benzodiazepines in patients with clearly defined SAWS and details a readily implementable protocol.
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Affiliation(s)
| | - Logan M Olson
- Department of Pharmacy, Nebraska Medicine, Omaha, NE, USA
| | - Derek A Kruse
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Elizabeth R Lyden
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, NE, USA
| | | | - Mindy M Blodgett
- Department of Critical Care Medicine, Nebraska Medicine, Omaha, NE, USA
| | - Alena A Balasanova
- Department of Psychiatry, University of Nebraska Medical Center, Omaha, NE, USA
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Terasaki D, Kulick B, Calcaterra S, Ray L. Phenobarbital for alcohol withdrawal in the context of the opioid epidemic: a neglected caveat. Addiction 2023; 118:1198-1200. [PMID: 36967706 PMCID: PMC10881280 DOI: 10.1111/add.16194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 03/10/2023] [Indexed: 04/12/2023]
Abstract
Phenobarbital interacts with the mortality-reducing opioid agonist therapies buprenorphine and methadone, risking delayed opioid withdrawal and relapse when administered concurrently. With increased adoption of phenobarbital into alcohol withdrawal protocols there should be safeguards in place to—in most cases—avoid phenobarbital for patients with a concurrent opioid use disorder.
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Affiliation(s)
- Dale Terasaki
- Department of Behavioral Health, Denver Health and Hospital Authority, Denver, CO, USA
| | - Brian Kulick
- Addiction Medicine Fellowship, University of Colorado School of Medicine, Aurora, CO, USA
| | - Susan Calcaterra
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Lance Ray
- Department of Acute Care Pharmacy, Denver Health and Hospital Authority, Denver, CO, USA
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Nishimura Y, Choi H, Colgan B, Kistler H, Mercado F. Current evidence and clinical utility of phenobarbital for alcohol withdrawal syndrome. Eur J Intern Med 2023; 112:52-61. [PMID: 36935249 DOI: 10.1016/j.ejim.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 02/28/2023] [Accepted: 03/06/2023] [Indexed: 03/21/2023]
Abstract
BACKGROUND Phenobarbital (PB) has been acknowledged among clinicians as a potential alternative to benzodiazepines (BZD) to decrease the need for hospital length of stay and complications associated with alcohol withdrawal syndrome (AWS). However, the level of evidence, including appropriate dosing, is unclear. We aim to summarize the evidence regarding PB used in AWS and provide future agendas for research. METHODS Following the PRISMA guidelines, we searched MEDLINE, EMBASE, ClinicalTrials.gov, and WHO ICTRP for all peer-reviewed articles and clinical trials using keywords including"alcohol withdrawal", "delirium tremens", "phenobarbital," and "barbiturate" from their inception to September 18, 2022. RESULTS We included 20 articles, nine in the emergency department (ED) and 11 in the general floors or intensive care units (ICUs). Studies performed in the ED included two RCTs, although both suffered from a considerably small sample size. Six studies done in the general floors or ICUs compared PB and BZD monotherapy, while four compared the utility of adjunct PB in addition to BZD compared with BZD monotherapy and one was a database study without specific dosing information. Overall, there was considerable heterogeneity in PB dosing, measured outcomes, and AWS severity measurement scales. CONCLUSION This systematic review summarizes the current evidence related to PB use in AWS. While considerable heterogeneity exists among studies available, PB as monotherapy without BZD may be a safe and effective alternative in AWS treatment. Future prospective studies or trials should focus on the standardization of PB dosing and outcomes.
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Affiliation(s)
- Yoshito Nishimura
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI, 96813, United States of America.
| | - Horyun Choi
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI, 96813, United States of America
| | - Bridget Colgan
- Department of Medicine, Tripler Army Medical Center, Honolulu, HI 96859, United States of America
| | - Harrison Kistler
- Department of Medicine, Tripler Army Medical Center, Honolulu, HI 96859, United States of America
| | - Francisco Mercado
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI, 96813, United States of America; Department of Medicine, Tripler Army Medical Center, Honolulu, HI 96859, United States of America
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Pourmand A, AlRemeithi R, Kartiko S, Bronstein D, Tran QK. Evaluation of phenobarbital based approach in treating patient with alcohol withdrawal syndrome: A systematic review and meta-analysis. Am J Emerg Med 2023; 69:65-75. [PMID: 37060631 DOI: 10.1016/j.ajem.2023.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 02/13/2023] [Accepted: 04/01/2023] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND Alcohol Withdrawal Syndrome (AWS) among patients with chronic and heavy alcohol consumption can range from mild to severe and is associated with high morbidity and mortality. Currently, treating AWS with benzodiazepines is the standard of care, but phenobarbital has also been hypothesized to be an effective first-line treatment due to its pharmacological properties and mechanism of action. We conducted a meta-analysis to review relevant literature and compare the clinical outcomes for patients diagnosed with AWS in ED and ICU settings. METHODS We performed a literature search in in the PubMed, Scopus, and Web of Science databases from inception to June 30, 2022. Randomized trials and observational (prospective or retrospective) studies were eligible if they included adult patients who presented in the ED and were treated in the ED and/or the intensive care unit (ICU) with a diagnosis of AWS. The primary outcome was the rate of intubation among patients who received phenobarbital, compared with benzodiazepines. Secondary outcomes such as rates of seizures, hospital, and ICU length of stay (LOS), also were included. The PROSPERO registration is CRD42022318862. RESULTS We included twelve studies (1934 patients) in our analysis. Of the 1934 patients in these studies, 765 (41.7%) were treated with phenobarbital and 1169 (58.3%) were treated with other modalities for alcohol withdrawal. Treating AWS patients with phenobarbital did not affect their risk for intubation, as the risk for intubation was similar between the phenobarbital and the control group (RR 0.70, 95% CI 0.36-1.38, P = 0.31). In addition, patients who were treated with phenobarbital were found to have similar rates of seizures (RR 0.73, 95% CI 0.29-1.89) and length of stay in the hospital (Standardized Mean Difference -0.02, 95% CI -0.26, 0.21) or the ICU (SMD -0.02, 95% CI -0.21, 0.25) when compared with patients receiving benzodiazepines. CONCLUSIONS Management of patients with AWS with phenobarbital is associated with similar rates of intubation, length of stay in the ICU, or length of stay in the hospital as treatment with benzodiazepines. However, due to the inclusion of mostly observational studies and a significant level of heterogeneity among the studies assessed in this review, additional trials with strong methodology are needed.
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Affiliation(s)
- Ali Pourmand
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, United States.
| | - Rashed AlRemeithi
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, United States.
| | - Susan Kartiko
- Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC, United States of America.
| | - David Bronstein
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, United States.
| | - Quincy K Tran
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America; Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States of America.
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Alwakeel M, Alayan D, Saleem T, Afzal S, Immler E, Wang X, Akbik B, Duggal A. Phenobarbital-Based Protocol for Alcohol Withdrawal Syndrome in a Medical ICU: Pre-Post Implementation Study. Crit Care Explor 2023; 5:e0898. [PMID: 37091477 PMCID: PMC10115550 DOI: 10.1097/cce.0000000000000898] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023] Open
Abstract
We assessed the efficacy and safety of PB compared with benzodiazepine (BZD)-based protocols in treating AWS in MICU. DESIGN Single-center, pre-post protocol implementation study. SETTING The setting is a forty-bed MICU in a tertiary-level academic medical center. PATIENTS We included all patients admitted to the MICU with a primary diagnosis of AWS. INTERVENTIONS Intravenous PB 260 mg followed by 130-mg doses every 15-30 minutes as needed up to 15 mg/kg of ideal body weight versus escalating doses of BZD, to achieve a Clinical Institute Withdrawal Assessment Alcohol Scale-Revised score less than 10. MEASUREMENTS AND MAIN RESULTS ICU and hospital length of stay (LOS), in addition to safety measures were the main outcomes of the study. A total of 102 patients were included, 51 in the PB arm and 51 in the BZD arm. There were no differences in baseline clinical characteristics. Half the patients in each group were admitted with delirium tremens. The use of PB-based protocol was associated with 35% reduction in median ICU LOS (1.5 d [interquartile range, 1.2-2.4 d] vs 2.3 d [1.4-4.8 d]; p = 0.009) and 50% reduction in hospital LOS (3 d [2.7-4 d] vs 6 d [4-10 d]; p < 0.001). After adjustment for comorbidities and clinical factors, PB protocol decreased ICU LOS days by 40% (95% CI; 25.8-53.5%). PB group required fewer adjunctive medications to control symptoms (0.7 [0.5-1] vs 2.5 [2-3]; p < 0.001), less need for intubation (1/51 [2%] vs 10/10 [19.6%]; p = 0.023) and less need for physical restraint (19/51 [37.3%] vs 29/51 [56.9%]; p = 0.047), compared with the BZD group. CONCLUSIONS A protocol utilizing rapidly escalating doses of PB over a short period is an effective and safe alternative to BZD in treating AWS in MICU.
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Affiliation(s)
- Mahmoud Alwakeel
- Department of Pulmonary & Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Dina Alayan
- Department of Internal Medicine, Cleveland Clinic Fairview Hospital, Cleveland, OH
| | - Talha Saleem
- Department of Pulmonary & Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Saira Afzal
- Neurology Department, Cleveland Clinic Florida, Weston, FL
| | - Ellen Immler
- Department of Pharmacy, Cleveland Clinic Fairview Hospital, Cleveland, OH
| | - Xiaofeng Wang
- Qualitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Bassel Akbik
- Critical Care Department, Houston Methodist, Houston, TX
| | - Abhijit Duggal
- Department of Pulmonary & Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
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Current and emerging therapies for alcohol-associated hepatitis. LIVER RESEARCH 2023. [DOI: 10.1016/j.livres.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
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Al-Maqbali JS, Al Alawi AM, Al-Mamari Q, Al-Huraizi A, Al-Maqrashi N. Symptoms-triggered approach versus fixed-scheduled approach of benzodiazepines for management of alcohol withdrawal syndrome: Non-randomized controlled trial. Alcohol 2023; 106:10-14. [PMID: 36240945 DOI: 10.1016/j.alcohol.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 09/29/2022] [Accepted: 09/29/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Alcohol withdrawal syndrome, if untreated, can lead to potentially life-threatening complications. Benzodiazepines are the drugs of choice for the treatment of alcohol withdrawal syndrome. We aimed to compare the symptoms-triggered approach and fixed-dose approach of benzodiazepine administration for treatment of alcohol withdrawal syndrome in regard to the health care utilization measured by the total dose of benzodiazepines, length of hospital stays, and 90-day readmissions rate. METHODS A single-center prospective non-randomized controlled trial included all patients diagnosed with alcohol withdrawal syndrome. The group of patients admitted between October 1, 2019, and September 30, 2020, were treated with the fixed-scheduled approach (n = 150), while all patients admitted between November 1, 2020, to October 31, 2021, were treated with the symptoms-trigger approach (n = 50). RESULTS The fixed-dose approach group showed a significant higher 90-day readmissions rate (HR: 2.61; 95% CI = 1.18, 6.84; p = 0.01). Kaplan-Meier survival analysis showed a significantly shorter duration to the first readmission in the fixed-scheduled approach group (HR: 2.3; 95% CI = 5.6, 1.16; p = 0.02). The symptoms-triggered approach group required a significantly lower dose of diazepam (40 mg vs. 10 mg; p < 0.01) and a higher dose of thiamine (800 mg vs. 600 mg; p < 0.01). Length of hospital stay was significantly increased in the symptoms-triggered approach group (3.9 vs. 2.2 days; p < 0.01). DISCUSSION The use of a symptoms-triggered approach to treat alcohol withdrawal syndrome was associated with a lower 90-day readmission rate, prolonged period to the first readmission, and reduced total dose of benzodiazepines, but longer length of hospital stays. CONCLUSION The symptoms-triggered approach is safe, cost-effective, and associated with reduced alcohol dependence relapse.
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Affiliation(s)
| | - Abdullah M Al Alawi
- Department of Medicine, Sultan Qaboos University Hospital, Muscat, Oman; Internal Medicine Training Program, Oman Medical Specialty Board, Muscat, Oman.
| | - Qasim Al-Mamari
- Department of Nursing, Sultan Qaboos University Hospital, Muscat, Oman
| | - Aisha Al-Huraizi
- Department of Medicine, Sultan Qaboos University Hospital, Muscat, Oman
| | - Nasiba Al-Maqrashi
- Internal Medicine Training Program, Oman Medical Specialty Board, Muscat, Oman
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Muacevic A, Adler JR, Muhammad S, Yousaf S, Nassar M, Ilyas U, Hosna AU, Parikh A, Bhangal R, Ahmed N, Ariyaratnam J, Trandafirescu T. Phenobarbital and Alcohol Withdrawal Syndrome: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e33695. [PMID: 36788902 PMCID: PMC9922035 DOI: 10.7759/cureus.33695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2023] [Indexed: 01/13/2023] Open
Abstract
Alcohol withdrawal syndrome (AWS) is a complication frequently encountered among patients who are chronic alcohol abusers. It is considered to have a significant impact on the United States healthcare system. It not only has a toll on the healthcare spending but also contributes to significant morbidity and mortality. Benzodiazepines are considered first line in the treatment of AWS. Since patients with alcohol use disorder have downregulated gamma aminobutyric acid (GABA) receptors, this often leads to benzodiazepine resistance. Phenobarbital is also used in the management of alcohol withdrawal syndrome. Here we present a systematic review and meta-analysis of the efficacy and safety of the drug. We conducted an electronic database search for relevant studies published between the inception of the project and November 20, 2022, in three databases, including Medline/PubMed, Embase, and Cochrane Library. Our study included all original studies with prime focus on the baseline characteristics of patients admitted to the intensive care unit (ICU) for alcohol withdrawal syndrome and management/monitoring protocol implemented for its treatment. The primary outcomes that were the focus of our study consisted of changes in the length of hospital stay, length of ICU stay, and changes in scoring systems (for alcohol withdrawal assessment and monitoring) following the implementation of phenobarbital. The secondary outcomes included complications such as intubation and mortality. Based on our analysis, the mean difference in hospital stay was statistically significant at -2.6 (95% CI, -4.48, -0.72, P=0.007) for phenobarbital compared to the benzodiazepine group. We were unable to comment on the heterogeneity in our meta-analysis due to the standard deviation not being reported in one study. There was no statistically significant difference regarding the length of stay in the intensive care unit compared to the control/comparative arm, with a mean difference of -1.17 (95% CI, -1.17, 0.09, P=0.07), with considerable heterogeneity (I2=77%, P=0.002). Our meta-analysis also investigated the risk of intubation between the phenobarbital and the control/comparative group. There was statistically significant difference in the incidence of intubation, relative risk (RR) 0.52 (95% CI, 0.25, 1.08, P=0.08), with considerable heterogeneity (I2=80%, P=0.0001). Our study concludes that phenobarbital is an effective tool in the management of AWS in an ICU setting. However, various studies have reported contradictory results, and vital information appears to be lacking. Moreover, there is a lack of uniformity in terms of phenobarbital dosing. Drug administration should be adapted according to the severity of the symptoms. Further studies need to be conducted discussing the safety profile and adverse effects of the drug when it comes to the management of alcohol withdrawal syndrome.
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Pistore A, Penney S, Bryce R, Meyer C, Bouchard B. A retrospective evaluation of phenobarbital versus benzodiazepines for treatment of alcohol withdrawal in a regional Canadian emergency department. Alcohol 2022; 102:59-65. [PMID: 35569673 DOI: 10.1016/j.alcohol.2022.05.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 05/02/2022] [Accepted: 05/06/2022] [Indexed: 11/01/2022]
Abstract
Evidence suggests that phenobarbital can be used to treat alcohol withdrawal syndrome as monotherapy; however, the therapeutic cornerstone remains benzodiazepines. To date, studies comparing the two treatment modalities in the emergency department (ED) are few. We sought to determine whether phenobarbital versus benzodiazepine monotherapy impacts ED length of stay and need for admission among adult presentations at a single regional hospital. In June 2019, a treatment algorithm offering both phenobarbital and diazepam pathways was introduced at the Battlefords Union Hospital ED, an 11-bed unit treating 27 000 patients annually in North Battleford, Saskatchewan, Canada. A subsequent retrospective observational study evaluated all adult alcohol withdrawal syndrome presentations between June 2019 and January 2021. Medical records were reviewed for visit date, age, sex, comorbidities, psychosocial factors, Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scores, secondary diagnoses, time of day, protocol adherence, attending physician, length of stay, disposition, and ED return. Descriptive statistics, log-rank testing, simple regression, and multiple regression were used in analysis. Of the 184 presentations, 30.4% were treated with phenobarbital. Median length of stay for phenobarbital versus benzodiazepine therapy was 4.4 h and 4.4 h, respectively (p = 0.21). Of the phenobarbital presentations, 9.4% were hospitalized versus 17.1% of the benzodiazepine presentations (p = 0.20). When adjusted for confounders, phenobarbital-treated presentations were 71.3% less likely to be admitted (p = 0.03). This research suggests that phenobarbital performs similarly to benzodiazepines regarding alcohol withdrawal ED length of stay and may result in reduced hospitalizations.
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Staidle A, Geier C. Phenobarbital and/or benzodiazepines for recurrent alcohol withdrawal: A self-controlled, retrospective cohort study. Am J Emerg Med 2022; 54:263-266. [DOI: 10.1016/j.ajem.2022.02.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 02/13/2022] [Accepted: 02/16/2022] [Indexed: 11/28/2022] Open
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Vigouroux A, Garret C, Lascarrou JB, Martin M, Miailhe AF, Lemarié J, Dupeyrat J, Zambon O, Seguin A, Reignier J, Canet E. Alcohol withdrawal syndrome in ICU patients: Clinical features, management, and outcome predictors. PLoS One 2021; 16:e0261443. [PMID: 34928984 PMCID: PMC8687554 DOI: 10.1371/journal.pone.0261443] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 12/01/2021] [Indexed: 12/01/2022] Open
Abstract
Background Alcohol withdrawal syndrome (AWS) is a common condition in hospitalized patients, yet its epidemiology in the ICU remains poorly characterized. Methods Retrospective cohort of patients admitted to the Nantes University Hospital ICU between January 1, 2017, and December 31, 2019, and coded for AWS using ICD-10 criteria. The objective of the study was to identify factors associated with complicated hospital stay defined as ICU length of stay ≥7 days or hospital mortality. Results Among 5,641 patients admitted to the ICU during the study period, 246 (4.4%) were coded as having AWS. Among them, 42 had exclusion criteria and 204 were included in the study. The three main reasons for ICU admission were sepsis (29.9%), altered consciousness (29.4%), and seizures (24%). At ICU admission, median Cushman’s score was 6 [4–9] and median SOFA score was 3 [2–6]. Delirium tremens occurred in half the patients, seizures in one fifth and pneumonia in one third. Overall, 48% of patients developed complicated hospital stay, of whom 92.8% stayed in the ICU for ≥7 days, 36.7% received MV for ≥7 days, and 16.3% died during hospital stay. By multivariable analysis, two factors were associated with complicated hospital stay: a higher number of organ dysfunctions at ICU admission was associated with a higher risk of complicated hospital stay (OR, 1.18; 95CI, 1.05–1.32, P = 0.005), whereas ICU admission for seizures was associated with a lower risk of complicated hospital stay (OR, 0.14; 95%CI, 0.026–0.80; P = 0.026). Conclusions AWS in ICU patients chiefly affects young adults and is often associated with additional factors such as sepsis, trauma, or surgery. Half the patients experienced an extended ICU stay or death during the hospital stay. The likelihood of developing complicated hospital stay relied on the reason for ICU admission and the number of organ dysfunctions at ICU admission.
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Affiliation(s)
- Aliénor Vigouroux
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
| | - Charlotte Garret
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
| | - Jean-Baptiste Lascarrou
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
| | - Maëlle Martin
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
| | - Arnaud-Félix Miailhe
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
| | - Jérémie Lemarié
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
| | - Julien Dupeyrat
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
| | - Olivier Zambon
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
| | - Amélie Seguin
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
| | - Jean Reignier
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
| | - Emmanuel Canet
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
- * E-mail:
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Murphy JA, Curran BM, Gibbons WA, Harnica HM. Adjunctive Phenobarbital for Alcohol Withdrawal Syndrome: A Focused Literature Review. Ann Pharmacother 2021; 55:1515-1524. [PMID: 33678057 DOI: 10.1177/1060028021999821] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To review the literature describing the use of adjunctive phenobarbital in the treatment of severe alcohol withdrawal syndrome (AWS). DATA SOURCES PubMed and EMBASE were searched using the following terms: phenobarbital, adjunct, refractory or treatment resistant, severe or complicated, and alcohol withdrawal delirium or alcohol withdrawal seizures. STUDY SELECTION AND DATA EXTRACTION The search was limited to randomized controlled trials (RCTs) and cohort studies published in English. DATA SYNTHESIS Seven studies were identified in the emergency department (ED; RCT, n = 1; cohort, n = 2), general medicine ward (cohort, n = 1), and intensive care unit (ICU; cohort, n = 3) settings. For all studies set in the ED and general medicine ward and for 1 ICU study, phenobarbital plus symptom-guided benzodiazepine therapy was compared to symptom-guided benzodiazepine monotherapy. The other 2 ICU studies examined adjunctive phenobarbital before and after implementation of a protocol, meaning patients in both arms could have received phenobarbital. Overall risk of bias across all studies was low to moderate. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE The specific role of adjunctive phenobarbital in AWS is not clear because a majority of studies are retrospective cohorts with varying primary outcomes in different patient care settings. CONCLUSIONS In the ED and general medicine ward, phenobarbital demonstrated benzodiazepine-sparing effects. In the ICU, when a protocol guides phenobarbital use, the need for mechanical ventilation may be reduced. Adjunctive phenobarbital was well tolerated. Because of study limitations, it is challenging to provide specific recommendations for adjunctive phenobarbital use in severe AWS.
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Vatsalya V, Li F, Frimodig J, Gala KS, Srivastava S, Kong M, Ramchandani VA, Feng W, Zhang X, McClain CJ. Repurposing Treatment of Wernicke-Korsakoff Syndrome for Th-17 Cell Immune Storm Syndrome and Neurological Symptoms in COVID-19: Thiamine Efficacy and Safety, In-Vitro Evidence and Pharmacokinetic Profile. Front Pharmacol 2021; 11:598128. [PMID: 33737877 PMCID: PMC7960760 DOI: 10.3389/fphar.2020.598128] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 12/10/2020] [Indexed: 12/19/2022] Open
Abstract
Coronavirus disease identified in 2019 (COVID-19) can be complicated by the Th17 cell-mediated IL-17 proinflammatory response. We tested if thiamine can effectively lower the Th17 response in a clinical study [Proinflammatory state in alcohol use disorder patients termed as disease controls (DC)] and corroborated the results using an in vitro study. We developed an effective dose range and model for key pharmacokinetic measures with the potential of targeting the cytokine storm and neurological symptoms of COVID-19. Three-week 200 mg dose of thiamine was administered to sixteen DC patients. Eight healthy volunteers (HV) were also included in this investigation. A subsequent in vitro study was performed to validate the effectiveness of thiamine [100 mg/day equivalent (0.01 μg/ml)] treatment in lowering the Th17 proinflammatory response in a mouse macrophage cell line (RAW264.7) treated with ethanol. Based on recent publications, we compared the results of the IL-17 response from our clinical and in vitro study to those found in other proinflammatory disease conditions (metabolic conditions, septic shock, viral infections and COVID-19) and effective and safe dose ranges of thiamine. We developed a pharmacokinetic profile for thiamine dose range as a novel intervention strategy in COVID-19. DC group showed significantly elevated proinflammatory cytokines compared to HV. Thiamine-treated DC patients showed significant lowering in IL-17 and increase in the IL-22 levels. In humans, a range of 79-474 mg daily of thiamine was estimated to be effective and safe as an intervention for the COVID-19 cytokine storm. A literature review showed that several neurological symptoms of COVID-19 (∼45.5% of the severe cases) occur in other viral infections and neuroinflammatory states that may also respond to thiamine treatment. Thiamine, a very safe drug even at very high doses, could be repurposed for treating the Th17 mediated IL-17 immune storm, and the subsequent neurological symptoms observed in COVID-19. Further studies using thiamine as an intervention/prevention strategy in COVID-19 patients could identify its precise anti-inflammatory role.
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Affiliation(s)
- Vatsalya Vatsalya
- Department of Medicine, University of Louisville, Louisville, KY, United States
- Robley Rex VA Medical Center, Louisville, KY, United States
| | - Fengyuan Li
- Department of Medicine, University of Louisville, Louisville, KY, United States
- University of Louisville Alcohol Research Center, Louisville, KY, United States
| | - Jane Frimodig
- Department of Medicine, University of Louisville, Louisville, KY, United States
- Robley Rex VA Medical Center, Louisville, KY, United States
| | - Khushboo S. Gala
- Department of Medicine, University of Louisville, Louisville, KY, United States
| | - Shweta Srivastava
- Department of Medicine, University of Louisville, Louisville, KY, United States
- Envirome Institute, University of Louisville, Louisville, KY, United States
| | - Maiying Kong
- Robley Rex VA Medical Center, Louisville, KY, United States
- Department of Bioinformatics and Biostatistics, University of Louisville, Louisville, KY, United States
| | - Vijay A. Ramchandani
- National Institute on Alcohol Abuse and Alcoholism, NIH, Bethesda, MD, United States
| | - Wenke Feng
- Department of Medicine, University of Louisville, Louisville, KY, United States
- University of Louisville Alcohol Research Center, Louisville, KY, United States
- Department of Pharmacology and Toxicology, University of Louisville, Louisville, KY, United States
- University of Louisville Hepatobiology and Toxicology COBRE, Louisville, KY, United States
| | - Xiang Zhang
- University of Louisville Alcohol Research Center, Louisville, KY, United States
- Department of Pharmacology and Toxicology, University of Louisville, Louisville, KY, United States
- University of Louisville Hepatobiology and Toxicology COBRE, Louisville, KY, United States
- Department of Chemistry, University of Louisville, Louisville, KY, United States
- Center for Regulatory and Environmental Analytical Metabolomics, University of Louisville, Louisville, KY, United States
| | - Craig J. McClain
- Department of Medicine, University of Louisville, Louisville, KY, United States
- Robley Rex VA Medical Center, Louisville, KY, United States
- University of Louisville Alcohol Research Center, Louisville, KY, United States
- Department of Pharmacology and Toxicology, University of Louisville, Louisville, KY, United States
- University of Louisville Hepatobiology and Toxicology COBRE, Louisville, KY, United States
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Hawa F, Gilbert L, Gilbert B, Hereford V, Hawa A, Al Hillan A, Weiner M, Albright J, Scheidel C, Al-Sous O. Phenobarbital Versus Lorazepam for Management of Alcohol Withdrawal Syndrome: A Retrospective Cohort Study. Cureus 2021; 13:e13282. [PMID: 33728215 PMCID: PMC7949711 DOI: 10.7759/cureus.13282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2021] [Indexed: 12/03/2022] Open
Abstract
Introduction Annually, 500,000 episodes of alcohol withdrawal syndrome (AWS) are severe enough to require clinical attention. A symptom-triggered lorazepam regimen remains the standard of care for the management of hospitalized AWS patients. However, phenobarbital has also been shown to be an effective adjunctive therapy for severe AWS, reducing benzodiazepine use in the emergency department (ED) and the intensive care unit (ICU). The purpose of this study is to compare hospital length of stay (LOS) for AWS patients using phenobarbital-based versus lorazepam-based treatment protocols as monotherapy for management of AWS on general medical units. Methods This is a retrospective cohort study over a two-year period (March, 2016 to March, 2018), conducted at three hospitals within the St. Joseph Mercy Health System. We included 606 patients with a primary diagnosis of AWS or alcohol intoxication who met our inclusion criteria (543 in the lorazepam cohort and 63 in the phenobarbital cohort). Adjusted comparisons were done using propensity scoring methods. Hospital LOS was set as the primary outcome. Secondary outcomes included all-cause 30-day readmission, alcohol-related 30-day readmission, 30-day ED visits after discharge, and need for ICU transfer during hospital stay. Results Patients who received phenobarbital had a statistically significant shorter hospital LOS as compared to patients who received lorazepam (2.8 versus 3.6 days, P < 0.001). Furthermore, the phenobarbital treatment group had statistically significant lower rates of all-cause 30-day readmission (11.11% versus 14.18%, P = 0.020) and 30-day ED visits after discharge (11.11% versus 18.6%, P = 0.015). No statistical significance was detected for alcohol-related 30-day readmission and the need for ICU transfer between the treatment groups. Conclusion This study suggests that phenobarbital may be a reasonable alternative to lorazepam in the management of AWS patients admitted to general medical units. Larger scale, well-executed, and adequately powered prospective studies and randomized controlled trials are needed to corroborate these findings.
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Affiliation(s)
- Fadi Hawa
- Internal Medicine, St. Joseph Mercy Ann Arbor Hospital, Ann Arbor, USA
| | - Linsey Gilbert
- Internal Medicine/Palliative Care, St. Joseph Mercy Ann Arbor Hospital, Ann Arbor, USA
| | - Benjamin Gilbert
- Internal Medicine, St. Joseph Mercy Livingston Hospital, Howell, USA
| | - Vanessa Hereford
- Internal Medicine, St. Joseph Mercy Livingston Hospital, Howell, USA
| | - Aya Hawa
- Pharmacy, St. Joseph Mercy Ann Arbor Hospital, Ann Arbor, USA
| | - Alsadiq Al Hillan
- Internal Medicine/Hepatology, Baylor College of Medicine, Houston, USA
| | - Mark Weiner
- Internal Medicine/Addiction Medicine, St. Joseph Mercy Ann Arbor Hospital, Ann Arbor, USA
| | - Jeremy Albright
- Statistics, St. Joseph Mercy Ann Arbor Hospital, Ann Arbor, USA
| | - Caleb Scheidel
- Statistics, St. Joseph Mercy Ann Arbor Hospital, Ann Arbor, USA
| | - Ola Al-Sous
- Internal Medicine, St. Joseph Mercy Ann Arbor Hospital, Ann Arbor, USA
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Therapeutic Prospects for Th-17 Cell Immune Storm Syndrome and Neurological Symptoms in COVID-19: Thiamine Efficacy and Safety, In-vitro Evidence and Pharmacokinetic Profile. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2020. [PMID: 32869036 DOI: 10.1101/2020.08.23.20177501] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Introduction Emerging infectious diseases, especially the coronavirus disease identified in 2019 (COVID-19), can be complicated by a severe exacerbation in the Th17 cell-mediated IL-17 proinflammatory immune storm. This enhanced immune response plays a major role in mortality and morbidity, including neurological symptoms. We hypothesized that countering the cytokine storm with thiamine may have therapeutic efficacy in lowering the Th17 cell proinflammatory response. We used an in vitro study and corroborated those results in disease controls (DC). We developed an effective dose range and model for key pharmacokinetic measures with the potential of targeting the cytokine storm and neurological symptoms of COVID-19. Study Participants and Methods We investigated the effect of a three-week 200 mg dose of thiamine in lowering the Th17 response in sixteen DC (proinflammatory origin due to heavy alcohol drinking) patients; and eight healthy control/volunteers (HV) as a pilot clinical-translational investigation. To further investigate, we performed an in vitro study evaluating the effectiveness of thiamine treatment in lowering the Th17 proinflammatory response in a mouse macrophage cell line (RAW264.7) treated with ethanol. In this in vitro study, 100 mg/day equivalent (0.01 ug/ml) thiamine was used. Based on recent publications, we compared the results of the IL-17 response from our clinical and in vitro study to those found in other proinflammatory disease conditions (metabolic conditions, septic shock, viral infections and COVID-19), including symptoms, and dose ranges of effective and safe administration of thiamine. We developed a dose range and pharmacokinetic profile for thiamine as a novel intervention strategy in COVID-19 to alleviate the effects of the cytokine storm and neurological symptoms. Results The DC group showed significantly elevated proinflammatory cytokines compared to HV. Three-week of 200 mg daily thiamine treatment significantly lowered the baseline IL-17 levels while increased IL-22 levels (anti-inflammatory response). This was validated by an in vitro macrophage response using a lower thiamine dose equivalent (100 mg), which resulted in attenuation of IL-17 and elevation of IL-22 at the mRNA level compared to the ethanol-only treated group. In humans, a range of 79-474 mg daily of thiamine was estimated to be effective and safe as an intervention for the COVID-19 cytokine storm. A literature review showed that several neurological symptoms of COVID-19 (which exist in 45.5% of the severe cases) occur in other viral infections and neuroinflammatory states that may also respond to thiamine treatment. Discussion The Th17 mediated IL-17 proinflammatory response can potentially be attenuated by thiamine. Thiamine, a very safe drug even at very high doses, could be repurposed for treating the cytokine/immune storm of COVID-19 and the subsequent neurological symptoms observed in COVID-19 patients. Further studies using thiamine as an interventional/prevention strategy in severe COVID-19 patients could identify its precise anti-inflammatory role.
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Glahn A, Proskynitopoulos PJ, Bleich S, Hillemacher T. Pharmacotherapeutic management of acute alcohol withdrawal syndrome in critically Ill patients. Expert Opin Pharmacother 2020; 21:1083-1092. [PMID: 32281894 DOI: 10.1080/14656566.2020.1746271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Alcohol withdrawal syndrome is a common and life-threatening condition in patients suffering from alcohol use disorder. Treatment of this syndrome is challenging, especially in patients that are critically ill, either because of withdrawal symptoms or underlying conditions. For the treatment, several pharmacological agents exist, such as benzodiazepines, barbiturates, or dexmedetomidine. Nonetheless, as alcohol withdrawal syndromes can occur in every clinical setting, it is necessary to provide a guideline for clinicians confronted with this syndrome in varying clinical contexts. AREAS COVERED The authors provide a systematic review of the literature found in PubMed and Embase following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. EXPERT OPINION For the treatment of alcohol withdrawal syndrome, medications targeting the GABA system are preferred. Benzodiazepines are regarded as the gold standard. However, as many adjunct therapeutic options exist, it is essential to find symptom-triggered approaches and treatment protocols for the variety of clinical contexts. Apart from that, it is necessary to compare protocols toward clinical variables rather than investigating medications that are in use for the treatment of alcohol withdrawal syndrome.
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Affiliation(s)
- A Glahn
- Department of Psychiatry, Psychotherapy and Social Psychiatry, Hannover Medical School , Hannover, Germany
| | - P J Proskynitopoulos
- Department of Psychiatry, Psychotherapy and Social Psychiatry, Hannover Medical School , Hannover, Germany
| | - S Bleich
- Department of Psychiatry, Psychotherapy and Social Psychiatry, Hannover Medical School , Hannover, Germany
| | - T Hillemacher
- Department of Psychiatry, Psychotherapy and Social Psychiatry, Hannover Medical School , Hannover, Germany.,Department of Psychiatry and Psychotherapy, Paracelcus Medical University , Nuremberg, Germany
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Nejad S, Nisavic M, Larentzakis A, Dijkink S, Chang Y, Levine AR, de Moya M, Velmahos G. Phenobarbital for Acute Alcohol Withdrawal Management in Surgical Trauma Patients-A Retrospective Comparison Study. PSYCHOSOMATICS 2020; 61:327-335. [PMID: 32199629 DOI: 10.1016/j.psym.2020.01.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 01/17/2020] [Accepted: 01/24/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Alcohol withdrawal syndrome (AWS) in surgical trauma patients is associated with significant morbidity and mortality. Benzodiazepines, commonly used for withdrawal management, pose unique challenges in this population given the high prevalence of head trauma and delirium. Phenobarbital is an antiepileptic drug that offers a viable alternative to benzodiazepines for AWS treatment. METHODS This is a retrospective chart review of patients with active alcohol use disorder who presented to a level 1 trauma center over a 4-year period and required medication-assisted management for AWS. The primary outcome variable examined was the development of AWS and associated complications. Additional outcomes measured included hospital length of stay, mortality, and medication-related adverse events. RESULTS Of the 85 patients in the study sample, 52 received a fixed-dose benzodiazepine-based protocol and 33 received phenobarbital-based protocol. In the benzodiazepine-based protocol group, 25 patients (48.2%) developed AWD and 38 (73.1%) developed uncomplicated AWS, as compared to 0 patients in the phenobarbital-based protocol (P = 0.0001). There were 10 (19.2%) patients with medication adverse side effects in the benzodiazepine-based protocol group versus 0 patients in the phenobarbital-based protocol group. There were no statically significant differences between the 2 groups as pertains to rates of other AWS-related complications, patient mortality, or length of stay. CONCLUSION The use of a phenobarbital-based protocol in trauma patients with underlying active alcohol use disorder resulted in a statistically significant decrease in the incidence of AWD and uncomplicated AWS secondary to AWS when compared to patients treated with a fixed-dose benzodiazepine-based protocol.
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Affiliation(s)
- Shamim Nejad
- Division of Psychosocial Oncology - Swedish Cancer Institute, Swedish Medical Center, Seattle, WA
| | - Mladen Nisavic
- Addiction Consult Service, Avery D. Weismann, Psychiatry Consultation Service, Department of Psychiatry, Massachusetts General Hospital & Harvard Medical School, Boston, MA; Department of Psychiatry, Harvard Medical School, Boston, MA.
| | - Andreas Larentzakis
- First Department of Propaedeutic Surgery, Hippokration General Hospital of Athens, Athens Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Suzan Dijkink
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Yuchiao Chang
- Trauma, Emergency Surgery and Surgical Critical Care Service, Massachusetts General Hospital, Boston, MA
| | - Alexander R Levine
- Assistant Professor of Pharmacy Practice, University of Saint Joseph School of Pharmacy, Department of Pharmacy Practice, Hartford, CT
| | - Marc de Moya
- Division of Trauma and Acute Care Surgery, Milton and Lidy Lunda/Charles Aprahamian Professor of Trauma Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - George Velmahos
- Trauma, Emergency Surgery and Surgical Critical Care Service, Massachusetts General Hospital, Boston, MA
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Love K, Zimmermann AE. Use of Propofol Plus Dexmedetomidine in Patients Experiencing Severe Alcohol Withdrawal in the Intensive Care Unit. J Clin Pharmacol 2019; 60:439-443. [PMID: 31663139 DOI: 10.1002/jcph.1539] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 10/08/2019] [Indexed: 11/05/2022]
Abstract
Alcohol abuse and alcohol withdrawal syndrome are major problems in the United States. This retrospective chart review assessed efficacy and safety of propofol plus dexmedetomidine used in combination as adjunctive therapy to benzodiazepines compared with either agent used alone in the treatment of severe alcohol withdrawal. Patients admitted to the intensive care unit and experiencing severe alcohol withdrawal between September 1, 2015 and September 30, 2018 were assessed for eligibility. Primary end points were change in the revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar) score and incidence of bradycardia and hypotension. The combination of propofol and dexmedetomidine was associated with a change in CIWA-Ar score of -10.4 (95%CI -13.5 to -7.3) points compared with -4.7 (95%CI -6.6 to -2.8) points with propofol and -4.4 (95%CI -7.4 to -1.4) with dexmedetomidine (P = .21). Bradycardia was experienced by 11.1% of patients receiving the combination, 15.4% of patients receiving propofol, and 28.6% of patients receiving dexmedetomidine (P = .40). Patients receiving dexmedetomidine experienced hypotension at a rate of 21.4% compared with 22.2% of patients receiving the combination and 38.5% of patients receiving propofol (P = .08). Patients in the combination group also had a shorter length of hospital and intensive care unit stay and shorter time to extubation when compared with the propofol and dexmedetomidine groups. Although no statistical significance was found, the combination was associated with better efficacy and safety outcomes than produced by either agent used alone.
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Affiliation(s)
- Kaylie Love
- Clinical Staff Pharmacist, Mercy Medical Center, Springfield, Massachusetts
| | - Anthony E Zimmermann
- Western New England University, College of Pharmacy & Health Sciences, Springfield, Massachusetts
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