Always On EM - Mayo Clinic Emergency Medicine Chapter 44 - Withdrawal warriors battle with barbs! Phenobarbital as a treatment for alcohol withdrawal
Jun 1, 2025
Brandy Hernandez, an Emergency Medicine pharmacist and PGY2 resident at Mayo Clinic, dives into the innovative use of phenobarbital for treating alcohol withdrawal. She discusses its benefits over traditional benzodiazepines and explores the mechanisms that make it effective. The conversation highlights the importance of personalized treatment plans, risks involved, and the intricacies of managing severe cases like Delirium Tremens. Brandy also shares insights into the evolving guidelines and the challenges healthcare providers face in this critical area of medicine.
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Phenobarbital's Unique Mechanism
- Phenobarbital's mechanism enhances GABA and prolongs calcium channel opening, unlike benzodiazepines that increase the frequency.
- It also acts on the ampikinate receptor, reducing neuronal excitability beyond benzodiazepines.
Alcohol Withdrawal Pathophysiology
- Alcohol withdrawal results from decreased GABA and increased glutamate activity disrupting neural balance.
- Replacement with GABAergic agents like benzodiazepines or phenobarbital helps restore inhibitory control.
Timing Alcohol Withdrawal Symptoms
- Watch for hallucinations within 6 days of last drink and tremors or insomnia up to 14 days.
- Seizures usually occur within 0-3 days; delirium tremens arise from 2-4 days after alcohol cessation.