SANTIAGO, Benjamin Jeremiah S.

2AMT

Journal Title: Benzodiazepines vs barbiturates for alcohol withdrawal: Analysis of 3 different

treatment protocols

About 8 million alcohol dependent patients suffer from alcohol withdrawal, and are taken
to the emergency department (ED) for treatment. The standard drugs often used to treat alcohol
withdrawal are benzodiazepines, and assessed with the employment of the Clinical Institute
Withdrawal Assessment (CIWA) or the Clinical Institute Withdrawal Assessment of Alcohol
Revised Scales. However, shortages in IV benzodiazepines requires hospitals to acquire
alternative treatment protocols for alcohol withdrawal. Given this, the study aims to describe
new institutional protocols involving the use of benzodiazepines and barbiturates in treating
alcohol withdrawal in the emergency department. In conducting the study, a single center,
retrospective observational cohort study was conducted at Denver Health Medical Center
(DHMC). Adult patients requiring treatment for acute alcohol withdrawal symptoms in the
emergency department from April 1, 2016 to January 31, 2018 participated in the study. All of
which were subjected to the ED Alcohol Withdrawal Severity of Ethanol Withdrawal Symptoms
Score (SEWS) Protocol. Only 3 separate protocols were developed for this study depending on
the availability of IV benzodiazepines and barbiturates. These protocols include diazepam alone,
intravenous lorazepam and intravenous phenobarbital, and intravenous phenobarbital alone. The
data of the study was collected from April 2016 to January 2017 for the diazepam only protocol,
June 2017 to july 2017 for the lorazepam and phenobarbital protocol, and December 2017 to
January 2018 for the phenobarbital only protocol. The results will primarily be measured based
on the rate of ICU admission from the emergency department, and secondarily measured based
on rate of mechanical ventilation, overall rate of hospitalization, length of hospital stay, total
dose of benzodiazepines, total dose of phenobarbital, and number of protocol violations.
Statistical tests used were the Mann-Whitney ​U and chi-square tests with a p-value of ≤0.05 for
statistical significance. There was no significant difference in the ICU admission of each
protocol. Significant differences were found in comparing the admission rates and length of stay,
admission rates were higher for the phenobarbital alone group than the diazepam group. The
average length of stay was lowest for those treated with lorazepam + phenobarbital, average ED
length of stay was lowest for those treated with diazepam only, average non-ICU floor length of
stay showed no difference between protocols, and lorazepam + phenobarbital had significantly
lower benzodiazepine equivalent requirements compared to the diazepam group. Given the result
for the rate if admission to the ICU, there is no need to increase mechanical ventilation in the
population and a decrease in the total consumption of benzodiazepine using a loading dose.
Overall, phenobarbital is safe and effective for patients presenting in the emergency department
in acute alcohol withdrawal, incorporating phenobarbital into benzodiazepine protocols resulted
to similar measures, and therefore a viable alternative for benzodiazepines.

Reference:
Kaucher, K.A., Kehoe, J., Mintzer, D., Nelson, A.C., Snakoff, J., Taub, J. (2019).
Benzodiazepines vs barbiturates for alcohol withdrawal: analysis of 3 different treatment
protocols. American Journal of Emergency Medicine. https://doi.org/10.1016/j.ajem.2019.01.002