January 10, 2019

Background: The mainstay of treatment for alcohol withdrawal syndrome is a symptom-triggered approach using benzodiazepines. Phenobarbital, however, is an interesting agent in this scenario for several reasons. It is famous for  it is long duration of action. IV Phenobarbital has an onset of action of over 15 – 20 minutes, a duration of action of 10 – 12 hours and a half-life of 53 – 118 hours in adults [5]. But phenobarbital has several other characteristics that make it attractive in the treatment of alcohol withdrawal. Importantly, it works on the GABA receptor differently than benzodiazepines. First, it increases the duration (not frequency) the chloride channel is open. Also, chronic alcohol abuse can alter the GABA receptor making it less sensitive to benzodiazepines not barbiturates. And finally, at very high doses, phenobarbital can open the chloride channel independent of the presence of GABA. The authors of this paper sought to compare a phenobarbital-adjunct versus benzodiazepine-only approach for the management of alcohol withdrawal syndrome in the ED.

April 28, 2016

Background: Severe alcohol withdrawal syndrome (AWS) accounts for only 10% of the roughly 500,000 annual cases of AWS episodes that require pharmacologic treatment. AWS is characterized by an imbalance between inhibitory GABA and excitatory NMDA receptor stimulation secondary to chronic ethanol intake. Treatment is typically centered around supportive care and symptom-triggered benzodiazepines. However, some patients are refractory to benzodiazepines, defined as > 10 mg lorazepam equivalents in 1 hour or > 40 mg lorazepam equivalents in 4 hours. Doses exceeding this threshold provide little benefit and put patients at risk for increase morbidity and mortality, over sedation, ICU delirium, respiratory depression and hyperosmolar metabolic acidosis.