Phenobarbital Treatment of Alcohol Withdrawal in the Emergency Department: A Systematic Review and Meta-analysis

Link to article at PubMed

Acad Emerg Med. 2023 Nov 3. doi: 10.1111/acem.14825. Online ahead of print.


OBJECTIVE: Despite frequent treatment of alcohol withdrawal syndrome (AWS) in the Emergency Department (ED), evidence for phenobarbital as an ED alternative therapy is mixed. We conducted a systematic review and meta-analysis comparing safety and efficacy of phenobarbital (PB) to benzodiazepines (BZD) 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 phenobarbital to benzodiazepine controls, and excluded studies focused on non-AWS conditions. Review was conducted by two blinded investigators and a third author; 8 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 (2 randomized controlled trials, 6 retrospective cohorts) comprised data from 1,507 patients in 2,012 treatment encounters for AWS. All studies were included in meta-analysis for adverse events, 7 for hospital admission, 5 for ICU admission, and 3 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 vs. BZD was 0.92 (95% 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 phenobarbital significantly reduces ICU admissions, hospital admissions, ED readmissions, or adverse events in ED patients with AWS compared with benzodiazepines alone.

PMID:37923363 | DOI:10.1111/acem.14825

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