Background: There are approximately 500,000 episodes of alcohol withdrawal that require pharmacologic treatment yearly. Lorazepam is commonly used due to its high therapeutic to-toxic effect index and its status as historically being the usual treatment. Phenobarbital is another common drug used to treat alcohol withdrawal. Patients with heavy alcohol use may become resistant to some effects of benzodiazepines, may experience rebound withdrawal, and may become over-sedated. Emerging evidence shows the use of phenobarbital for alcohol withdrawal is just as safe if not safer than using benzodiazepines. (2017, Hammond et al)A shortage of lorazepam led to the use of phenobarbital in the treatment of alcohol withdrawal at our tertiary care hospital. Our study hopes to compare which protocol was more efficacious while causing the least amount of side effects.
Methods: A total of 143 charts from patients admitted in the fall of 2021 with a diagnosis of alcohol withdrawal. Charts were reviewed for:1. Baseline characteristics: Blood EtOH, sex, race, ethnicity, age,weight, AST/ALT, Dialysis, Creatinine, Bilirubin, INR, Na, MELD score ifhistory of liver disease, history of respiratory disease, history of alcoholwithdrawal, history of delirium tremens, history of alcohol withdrawal seizures.2. Initial CIWA Score3. Max CIWA score in first 24 hours.4. Total dose required to bring patient to CIWA score of 9X2 5. Total dose required to get to discharge6. Length of time (phenobarbital or phenobarbital + benzo) from onset oftreatment to CIWA of 97. LOS8. Side effects (MICU treatment, respiratory depression, intubation,liver disease issues, infection)9. CostInclusion criteria are patients admitted for alcohol withdrawal requiring pharmacological treatment with either lorazepam or phenobarbital. The period of lorazepam monotherapy treatment directly preceded the period of time when phenobarbital was used as monotherapy to minimize any confounding variables. Exclusion criteria include patients under the age of 18, pregnant patients, and prisoners. This study is IRB-approved.
Results: A total of 209 charts of patients admitted with alcohol withdrawal were screened for enrollment, 143 of those were enrolled. Of the 143 patients, 59 patients were given Lorazepam, and 84 were given phenobarbital. The average initial CIWA score on admission for the Lorazepam group was 9.6 and 7.83 for the phenobarbital group. The lorazepam group had more adverse events (none related to medications) with a total of 24 events compared to the phenobarbital group with 17 adverse events. The lorazepam group on average received higher doses of medications including chlordiazepoxide. The lorazepam group on average stayed hospitalized longer for an average of 7.9 days compared to the phenobarbital group with an average of 5.46 days. In a recent search for hospital expenses per inpatient day, the average cost of hospitalizations per day for our state’s non-profit hospitals was $2,973. Applying that number to the average length of stay between the lorazepam and phenobarbital group, it is possible to save an average amount of $7,252.12 per inpatient stay.
Conclusions: Patients who receive phenobarbital for alcohol withdrawal have a significantly shorter length of stay compared to patients receiving lorazepam.