Alcohol Withdrawal Syndrome Treated With Adjunctive Phenobarbital or Ketamine
- Conditions
- Alcohol Withdrawal Syndrome
- Interventions
- Registration Number
- NCT03788889
- Lead Sponsor
- Santa Barbara Cottage Hospital
- Brief Summary
The goal of this study will aim to determine if adding phenobarbital or ketamine to a symptom-triggered benzodiazepine regimen decreases the rate of intensive care unit admissions during the treatment of alcohol withdrawal syndrome when compared to symptom-triggered benzodiazepine therapy alone.
- Detailed Description
The primary objective of this study is to compare phenobarbital and ketamine adjunctive therapies to lorazepam-based therapy in the treatment of acute alcohol withdrawal syndrome.
It is hypothesized that the use of an alternative agent, either phenobarbital or ketamine, when used as an adjunct to symptom-triggered lorazepam therapy will significantly reduce the rate of intensive care unit admissions and thereby reduce the total cost associated with hospital admission for treatment of alcohol withdrawal syndrome.
Enrolled patients will be admitted to Santa Barbara Cottage Hospital where they will be monitored with continuous pulse oximetry and cardiac telemetry. They will remain hospitalized while undergoing study-guided therapy in addition to supportive care for acute alcohol withdrawal syndrome. Patients will undergo standard of care therapy with lorazepam symptom-triggered therapy regardless of study participation.
Recruitment & Eligibility
- Status
- WITHDRAWN
- Sex
- All
- Target Recruitment
- Not specified
- Primary admitting diagnosis of acute alcohol withdrawal syndrome based on International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10), code F10.3, F10.4.
- Significant comorbid medical illness requiring Intensive Care Unit admission;
- Pregnancy;
- Inability to obtain intravenous access;
- Child Pugh Class C; and
- Allergy to study medications (phenobarbital, ketamine, lorazepam).
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description Lorazepam + Ketamine + Placebo A Placebo A Ketamine - infusion (0.15 - 0.4 mg/kg/hr) and placebo injections titrated by increases of 0.075 mg/kg/hr every 30 minutes for Clinical Institute Withdrawal Assessment for Alcohol (revised version) (CIWA-Ar) greater than or equal to 10 in addition to lorazepam symptom-triggered therapy Ketamine dosing will be based on ideal body weight Ketamine infusion will be discontinued once CIWA-Ar less than 10 for 4 hours Lorazepam + Phenobarbital + Placebo B Placebo B Phenobarbital - IV push (260 mg loading followed by 130 mg q1 hour) with placebo infusion until CIWA-Ar less than 10 with a maximum daily dose of 10mg/kg in addition to lorazepam symptom-triggered dosing for recurrent symptoms (Gold 2007) Maximum daily dose will be used in order to prevent over sedation as well as provide adequate storage in pharmacy monitored refrigerators for study drugs Lorazepam + Placebo A + Placebo B Placebo A Lorazepam will be administered every 30 minutes as indicated based on CIWA-Ar protocol for Cottage Health in addition to placebo injections and placebo infusion Lorazepam + Placebo A + Placebo B Placebo B Lorazepam will be administered every 30 minutes as indicated based on CIWA-Ar protocol for Cottage Health in addition to placebo injections and placebo infusion Lorazepam + Ketamine + Placebo A Ketamine Ketamine - infusion (0.15 - 0.4 mg/kg/hr) and placebo injections titrated by increases of 0.075 mg/kg/hr every 30 minutes for Clinical Institute Withdrawal Assessment for Alcohol (revised version) (CIWA-Ar) greater than or equal to 10 in addition to lorazepam symptom-triggered therapy Ketamine dosing will be based on ideal body weight Ketamine infusion will be discontinued once CIWA-Ar less than 10 for 4 hours Lorazepam + Ketamine + Placebo A Lorazepam Ketamine - infusion (0.15 - 0.4 mg/kg/hr) and placebo injections titrated by increases of 0.075 mg/kg/hr every 30 minutes for Clinical Institute Withdrawal Assessment for Alcohol (revised version) (CIWA-Ar) greater than or equal to 10 in addition to lorazepam symptom-triggered therapy Ketamine dosing will be based on ideal body weight Ketamine infusion will be discontinued once CIWA-Ar less than 10 for 4 hours Lorazepam + Phenobarbital + Placebo B Phenobarbital Phenobarbital - IV push (260 mg loading followed by 130 mg q1 hour) with placebo infusion until CIWA-Ar less than 10 with a maximum daily dose of 10mg/kg in addition to lorazepam symptom-triggered dosing for recurrent symptoms (Gold 2007) Maximum daily dose will be used in order to prevent over sedation as well as provide adequate storage in pharmacy monitored refrigerators for study drugs Lorazepam + Phenobarbital + Placebo B Lorazepam Phenobarbital - IV push (260 mg loading followed by 130 mg q1 hour) with placebo infusion until CIWA-Ar less than 10 with a maximum daily dose of 10mg/kg in addition to lorazepam symptom-triggered dosing for recurrent symptoms (Gold 2007) Maximum daily dose will be used in order to prevent over sedation as well as provide adequate storage in pharmacy monitored refrigerators for study drugs Lorazepam + Placebo A + Placebo B Lorazepam Lorazepam will be administered every 30 minutes as indicated based on CIWA-Ar protocol for Cottage Health in addition to placebo injections and placebo infusion
- Primary Outcome Measures
Name Time Method Intensive Care Unit admission rate Presentation to Emergency Department through hospital stay, data will be utilized through study completion, anticipated 2 years Number of admissions to the intensive care unit
- Secondary Outcome Measures
Name Time Method Incidence of withdrawal seizures Presentation to Emergency Department through hospital stay, data will be utilized through study completion, anticipated 2 years Number of patients with documented seizures while treated for alcohol withdrawal syndrome
Incidence of alcohol withdrawal hallucinations Presentation to Emergency Department through hospital stay, data will be utilized through study completion, anticipated 2 years Number of patients with documented auditory or visual hallucinations
Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) scores Presentation to Emergency Department through hospital stay, data will be utilized through study completion, anticipated 2 years CIWA-Ar scores (initial, maximum, discharge); Total score is cumulative of subscale measures: Minimum score is 0 (no evidence of alcohol withdrawal), Maximum score is 67 (severe alcohol withdrawal)
Subscale measures:
A) Nausea and vomiting (score 0-7); B) Tremor (score 0-7); C) Paroxysmal sweats (score 0-7); D) Anxiety (score 0-7); E) Tactile disturbances (score 0-7); F) Auditory disturbances (score 0-7); G) Visual disturbances (score 0-7); H) Headache, fullness in head (score 0-7); I) Agitation (score 0-7); J) Orientation and clouding of sensorium (score 0-4)Cumulative dose of medication/s administered Presentation to Emergency Department through hospital stay, data will be utilized through study completion, anticipated 2 years Cumulative dose of Lorazepam, Ketamine, and Phenobarbital
Rate of mechanical ventilation Presentation to Emergency Department through hospital stay, data will be utilized through study completion, anticipated 2 years Rate of intubation
Incidence of refractory alcohol withdrawal requiring alternative sedation with dexmedetomidine, propofol or midazolam infusions Presentation to Emergency Department through hospital stay, data will be utilized through study completion, anticipated 2 years Number of patients who require Dexmedetomidine, Propofol or Benzodiazepine continuous infusions and average dose while being treated for alcohol withdrawal syndrome