Phenobarbital for alcohol withdrawal management in the emergency department: A systematic review of direct evidence for the SAEM GRACE initiative

Review (2 RCTs, 5 retrospective; n=1,034) found phenobarbital did not differ significantly from benzodiazepine for most outcomes (RCTs). Retrospective data indicate it is associated with higher discharge and lower odds of subsequent A&E visit vs benzodiazepine-only treatment.

SPS commentary:

The authors note the paucity of direct evidence for the utility of phenobarbital in this setting, and the heterogeneity of the included studies precluded valid meta-analysis, with variations across studies in populations included, inclusion/exclusion criteria applied, and treatment protocols administered.  However, the aggregated evidence was generally supportive; in particular, there was relatively consistent evidence for improved outcomes when it is used in addition to benzodiazepines. They call for methodologically rigorous large-scale RCTs investigating the superiority or noninferiority of phenobarbital monotherapy compared to benzodiazepine treatments and the potential superiority of combination phenobarbital and benzodiazepine protocols in the emergency department.

Academic Emergency Medicine