From the Guidelines
Phenobarbital is not recommended as a first-line treatment for alcohol withdrawal syndrome, and benzodiazepines should be considered the primary treatment option. According to the EASL clinical practice guidelines for the management of alcohol-related liver disease 1, benzodiazepines are considered the 'gold standard' treatment for AWS due to their efficacy in reducing withdrawal symptoms and the risk of seizures and/or delirium tremens.
The guidelines suggest using a symptom-triggered regimen rather than a fixed dose schedule to prevent the accumulation of the drug, and recommend long-acting benzodiazepines (e.g. diazepam, chlordiazepoxide) for their protective effects against seizures and delirium, while short and intermediate-acting benzodiazepines (e.g. lorazepam, oxazepam) are safer in elderly patients and those with hepatic dysfunction 1.
Some key points to consider when managing AWS include:
- Using severity scores such as the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) to assess the severity of AWS
- Implementing a symptom-triggered treatment approach to prevent over-sedation and accumulation of the drug
- Selecting the appropriate benzodiazepine based on the patient's individual needs and medical history
- Monitoring patients closely for signs of withdrawal, sedation, and potential complications such as respiratory depression.
It is essential to prioritize the use of benzodiazepines as the primary treatment option for AWS, given their established efficacy and safety profile, as recommended by the EASL clinical practice guidelines 1.
From the FDA Drug Label
DRUG ABUSE AND DEPENDENCE Barbiturate-dependent patients can be withdrawn by using a number of different withdrawal regimens. One method involves substituting a 30 mg dose of phenobarbital for each 100 to 200 mg dose of barbiturate that the patient has been taking The total daily amount of phenobarbital is then administered in 3 to 4 divided doses, not to exceed 600 mg daily. Individuals susceptible to barbiturate abuse and dependence include alcoholics and opiate abusers, as well as other sedative-hypnotic and amphetamine abusers Symptoms of barbiturate dependence are similar to those of chronic alcoholism.
The use of phenobarbital for alcohol withdrawal is not directly supported by the provided drug label. However, it does mention that alcoholics are susceptible to barbiturate abuse and dependence, and that symptoms of barbiturate dependence are similar to those of chronic alcoholism.
- The label provides a regimen for withdrawing barbiturate-dependent patients using phenobarbital, but it does not explicitly address the use of phenobarbital for alcohol withdrawal.
- Phenobarbital may be used to manage barbiturate withdrawal, but its use for alcohol withdrawal is not directly mentioned in the label 2.
From the Research
Phenobarbital for Alcohol Withdrawal
- Phenobarbital is an alternative to benzodiazepines for managing alcohol withdrawal syndrome (AWS) 3, 4, 5
- Studies have shown that phenobarbital can be effective in reducing AWS symptoms and decreasing the need for benzodiazepines 3, 4, 5
- A retrospective chart review found that patients treated with phenobarbital had similar primary and secondary treatment outcomes to those treated with benzodiazepines, despite being more likely to have a history of prior complications related to AWS 3
- Another study found that phenobarbital decreased AWS symptoms and displayed similar rates of treatment failure versus comparator therapies 4
- A systematic review found that phenobarbital, with or without concomitant benzodiazepines, may provide similar or improved outcomes when compared with alternative therapies, including benzodiazepines alone 4
Comparison to Benzodiazepines
- Benzodiazepines are still considered the first-line treatment for alcohol withdrawal 6
- However, phenobarbital has been shown to be a reasonable alternative to lorazepam in the management of AWS patients admitted to general medical units 5
- A study found that patients who received phenobarbital had a statistically significant shorter hospital length of stay as compared to patients who received lorazepam 5
- Another study found that diazepam, a benzodiazepine, should be the preferred benzodiazepine for the treatment of patients experiencing moderate to severe alcohol withdrawal under most circumstances 7
Safety and Efficacy
- Phenobarbital has been shown to be safe and effective in managing AWS, with rare adverse effects such as dizziness and drowsiness 4
- A study found that phenobarbital decreased the need for mechanical ventilation and decreased benzodiazepine requirements by 50% to 90% 4
- However, larger scale, well-executed, and adequately powered prospective studies and randomized controlled trials are needed to corroborate these findings 3, 5