Hospital Pharmacy - October 2017 - 612

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Hospital Pharmacy 52(9)

Figure 1. Article Inclusion/Exclusion.

(preguideline: n = 54; postguideline: n = 41). Significant
increases in PHB use and total diazepam dose administered
were found in the postguideline group (58.0% vs 17.0%, P <
.001; 562 mg vs 248 mg, P < .001, respectively). There was
a significant reduction in the use of mechanical ventilation
postguideline (21.9% vs 47.3%, P = .008). Mechanical ventilation was most commonly used for airway protection for
all patients. There were no differences in ICU LOS or the
overall incidence of nosocomial pneumonia. ICU LOS was
greater in patients who required mechanical ventilation,
regardless of type of guideline used. Although PHB was used
after escalating doses of diazepam and in only 58% of
patients in the postguideline group compared with 17% in
the preguideline group, its use may have contributed to
decreasing mechanical ventilation in this study. The reduction in BZD requirements likely was a result of the protocolized guideline rather than PHB.
Mild-to-moderate AWS. Gashlin and colleagues performed a
retrospective cohort study at a single-center using 2 AWS
cohorts: treatment with BZDs alone and treatment with
BZDs plus PHB.20 To qualify for the BZD-only group,
patients had to receive at least 3 oral diazepam doses of 20
mg (or equivalent) within 6 hours. All other patients were in
the BZD and PHB group, but the authors did not indicate the
strategy for selection of PHB use in patients. All patients had
at least 1 CIWA-Ar score greater than 10. Patients directly
admitted to the ICU for AWS treatment initiation were
excluded. The primary outcome was the proportion of

patients with a CIWA-Ar score less than 10 at 24 hours after
AWS treatment initiation. A total of 28 patients were evaluated (BZD-only: n = 21; BZD and PHB: n = 7). There was no
difference in the primary outcome between the BZD-only
and BZD plus PHB groups (23.8% vs 28.6%, respectively;
P = .588). The median duration of AWS symptoms was also
similar between groups. Median BZD requirements were
lower in the BZD plus PHB group (25 mg vs 326 mg; P =
.02). The median cumulative PHB dose was 455 mg (interquartile range, 309- 618 mg), which equated to a median 6.3
mg/kg dose per patient. Evaluation of safety end points (eg,
requirement for intubation or ICU admission) was similar
between the 2 groups. PHB appears to only reduce BZD
requirements in this study, while maintaining a good safety
profile compared with BZDs only.
Summary. Use of intravenous PHB with concomitant BZDs
appears to offer some potential benefits, although it is difficult to determine whether these benefits are due to more
intentional and protocolized care or due to the administration
of PHB itself. Although data are limited, when used as a single, large dose in the ED as part of a front-loading strategy in
order to gain control of AWS symptoms, PHB appears to
reduce the need for ICU admission rates and is well tolerated. When added to dose escalation of BZDs, decreases in
length of mechanical ventilation and ICU LOS have been
shown. However, this may be due to just more intentional
treatment with GABA agonists and not solely due to the benefits of PHB itself. Despite an overall small sample of

Table of Contents for the Digital Edition of Hospital Pharmacy - October 2017