(1465) Monotherapy Phenobarbital vs Benzodiazepines for AWS in ICU: A Systematic Review and Meta-Analysis

Introduction: Alcohol Withdrawal Syndrome (AWS) in the intensive care unit (ICU) presents a serious clinical challenge. Various treatment options have been explored for managing AWS in the ICU setting with mixed outcomes. In this study, we aimed to compare the effectiveness and safety of benzodiazepines (BZD), the standard of care, with that of phenobarbital (PB), a treatment option that has shown promising results.

Methods: The literature review used an electronic search of Embase® and PubMed® to January 2024. We selected studies involving patients over 18 years old admitted to the ICU for AWS treatment with either PB or BZDs. Primary outcomes was risk of intubation, with secondary outcomes being ICU and hospital length of stay (LOS).Two reviewers assessed the studies for risk of bias using the NOS scale, while the certainty of evidence was evaluated with the GRADE approach. A random-effects meta-analysis was conducted to assess primary and secondary outcomes using risk ratios and weighted mean differences. Heterogeneity was measured with the I² value and Cochrane's Q-statistic, and publication bias was examined through funnel plots and Egger's test.

Results: Out of 675 studies reviewed, 18 were included in the final analysis. Most studies were retrospective and single-centered. All studies had NOS score ≥7 except for three scoring 6. A total of 1957 patients were included in the analysis. For intubation, patients with AWS treated with PB experienced a 48.6% reduction in risk compared to those treated with BZDs (RR = 0.514, 95% CI: 0.266-0.994, p = 0.048). Significant heterogeneity (Cochran's Q = 72.34, df = 12, p < 0.0001), with an I² value of 83.4% (95% CI: 5.1%-93.4%), indicating substantial variability. No significant difference was observed in ICU or hospital LOS. The study's limitations include reliance on observational studies, the use of data from abstracts with additional information requested from authors, and the absence of RCTs.

Conclusions: In conclusion, PB significantly reduces the risk of intubation in patients with AWS compared to BZDs. However, there is no significant difference in ICU or hospital LOS between the two treatments. The analysis revealed substantial heterogeneity, emphasizing the need for further high-quality studies, particularly RCTs, to confirm these findings.