Department of Psychology, Neuroscience, and Behaviour, McMaster University, Ontario, Hamilton, Canada.
Peter Boris Centre for Addictions Research, St. Joseph's Healthcare Hamilton/McMaster University, Hamilton, Ontario, Canada.
Acad Emerg Med. 2024 May;31(5):481-492. doi: 10.1111/acem.14788. Epub 2023 Sep 2.
Alcohol withdrawal syndrome (AWS) is a commonly presenting condition in the emergency department (ED) and can have severe complications, including mortality. Benzodiazepines are first-line medications for treating AWS but may be unavailable or insufficient. This systematic review evaluates the direct evidence assessing the utility of phenobarbital for treating AWS in the ED.
A systematic search was conducted and designed according to the patient-intervention-comparator-outcome (PICO) question: (P) adults (≥18 years old) presenting to the ED with alcohol withdrawal; (I) phenobarbital (including adjunctive); (C) benzodiazepines or no intervention; and (O) AWS complications, admission to a monitored setting, control of symptoms, adverse effects, and adjunctive medications. Two reviewers independently assessed articles for inclusion and conducted risk of bias assessments for included studies.
From 70 potentially relevant articles, seven studies met inclusion criteria: three retrospective cohort studies, two retrospective chart reviews, and two randomized controlled trials (RCTs), one examining phenobarbital monotherapy and one examining adjunctive phenobarbital. Across the retrospective cohort studies, treatment of AWS with phenobarbital resulted in lower odds of a subsequent ED visit. The retrospective chart reviews indicated that phenobarbital was associated with higher discharge rate compared to benzodiazepine-only treatments. For the two RCTs, phenobarbital did not differ significantly from benzodiazepine for most outcomes, although concomitant treatment with phenobarbital was associated with lower benzodiazepine use and intensive care unit admission. The heterogeneous designs and small number of studies prevented quantitative synthesis.
Relatively few studies provide direct evidence on the utility of phenobarbital for AWS in the ED, but the evidence that exists generally suggests that it is a reasonable and appropriate approach. Additional RCTs and other methodologically rigorous investigations are needed for more definitive direct evidence.
酒精戒断综合征（AWS）是急诊科常见的病症，可能会出现严重并发症，包括死亡。苯二氮䓬类药物是治疗 AWS 的一线药物，但可能无法获得或剂量不足。本系统评价评估了苯巴比妥治疗急诊科 AWS 的直接证据。
根据患者干预比较结局（PICO）问题进行系统搜索和设计：（P）成年（≥18 岁）患者因酒精戒断就诊急诊科；（I）苯巴比妥（包括辅助治疗）；（C）苯二氮䓬类药物或无干预；（O）AWS 并发症、入住监测病房、症状控制、不良反应和辅助药物。两名评审员独立评估纳入的文章，并对纳入研究进行偏倚风险评估。
从 70 篇可能相关的文章中，有 7 篇研究符合纳入标准：3 项回顾性队列研究、2 项回顾性图表审查和 2 项随机对照试验（RCT），其中 1 项研究检查了苯巴比妥单药治疗，1 项研究检查了辅助苯巴比妥治疗。在回顾性队列研究中，AWS 用苯巴比妥治疗与随后急诊科就诊的可能性降低相关。回顾性图表审查表明，与仅使用苯二氮䓬类药物的治疗相比，苯巴比妥治疗与更高的出院率相关。对于 2 项 RCT，与苯二氮䓬类药物相比，苯巴比妥在大多数结局上无显著差异，但与苯巴比妥联合治疗相关的苯二氮䓬类药物使用和入住重症监护病房的可能性降低。研究设计的异质性和研究数量少，妨碍了定量综合。
相对较少的研究提供了苯巴比妥治疗急诊科 AWS 的直接证据，但现有的证据普遍表明这是一种合理且适当的方法。需要更多的 RCT 和其他方法学严谨的研究来提供更明确的直接证据。
