Artificial Intelligence: Best Practices in Primary Care to Achieve the Quintuple Aim (Toub, 5/28/25)

 A recording of this presentation is available HERE.

Pathologizing Queer Patients (Harlow, 5/14/2025)

 A recording of this presentation is available HERE.

Care of Patients with Developmental Disabilities (French, 5/7/25)

 A recording of this presentation is available HERE.

***

Many, many thanks to Dr. Anne French, SRFMR Class of '99, who gave a pearl-filled presentation today about caring for patients with autism. Dr. French's many years of caring for patients with Intellectual and Developmental Disabilities (IDD) at Sonoma Developmental Center and now at Santa Rosa Community Health are literally priceless. We are so lucky to have her wisdom!

Please do watch her presentation. 

For those of you who prefer the Cliff's notes and pearls:

• always presume confidence when speaking with an autistic patient (even if non-verbal), speak as if they understand (they often do!)
• autism is often accompanied by other psych comorbidities, including anxiety disorders: GAD, OCD, and disordered sleep -- to name a few-- which impede function at school and work
• other psychiatric comorbidities also exist, including bipolar disorder and ADHD. These may be challenging to tease out
• look for anxiety
• consider GABA, fish oil, probiotics (for parents who don't want to use meds)
• r/o ADHD w/Vanderbilt
• okay to do trial of meds like Strattera without psychiatrist consult
• when you see self-injurious behavior (SIB), think physical discomfort (e.g. allergies, headaches)-- naltrexone can be a miraculous treatment for some with SIB (doesn't always work, but blocks the reward pathway for SIB)
• Dr. French highly recommends the use of Gene Sight, which is covered by both Medicare and Medi-Cal. It is intended to help prescribers understand how individuals process psych meds differently
• can help avoid medications that will have problematic effects
• gives MTHFR status (folate), which can be supplemented. Of note,  patients with autism tend to have decreased folate
• Physicians can only refer autism evaluation to the Northbay Regional Center before age 3, but parents can self refer after that. Give parents the phone number and email address of NBRC if they need to self-refer.
• Dr. MacLeamy is a clinical psychologist in Petaluma. He and associates have the PHP contract to diagnose autism in SoCo
• Applied behavioral analysis (ABA) Therapy, parents can self-refer, certified behavioralists can help treat at home/school (e.g. getting autistic kids to take shower, brush teeth, manage school day)>> many people with autism need extra support to reach their milestones
• Always look for physical causes of agitation (e.g. allergies, dental pain, constipation)
• Social stories is a simple way to teach people with autism, about social situations and expected behaviors (e.g. this is what happens when you go to the doctor, airport, pap smear, etc)
• Use EMLA cream for lab draws
• Medications that help with dysregulation include propranolol, clonidine, guanfacine, May be helpful.
• Disordered sleep should be treated. Extra challenging in children (limited options). Consider melatonin, 5HTP, Consider Buspar (age >6).
• Parents can get defensive and feel othered by the healthcare system. Building relationship and trust with them is key!
• Polypharmacy is a HUGE problem, particularly notable is multiple antipsychotics in boys/men with autism during and after puberty.
• Deprescribe antipsychotics when possible>> start with highest risk meds, if 2 of something, take one away
• Oversedation may occur with age
• Falls and/or ataxia can also be an issue with polypharmacy as patients with IDD age

Gene Sight report

Primary Care for Recent Immigrants (Kasten-Arias 4/2025)

A recording of this presentation is available HERE.

***

Many thanks to Dr. Cassandra Kasten-Arias, who gave our final Senior Resident presentation of the academic year. Don't worry, we still have a few more weeks of Grand Rounds before we take a summer break. Dr. Kasten-Arias gave an important and timely presentation on Primary Care in Recent Immigrants. 

The first part of her talk featured the medical indications for specific screening tests for refugees and/or recent immigrants; the second half focused on recent executive policy changes and what clinicians need to know to reassure patients about their rights and to respond to the presence of immigration officials in clinic and hospital spaces. I recommend watching!

For those of you who prefer notes:

Those of us who work in community health are aware of the immigrant populations we currently care for in our particular communities. As seen in the images below, the largest share of immigrants in the US are from Mexico, followed by India and China. In contrast, the largest number of refugees in the US currently are from China, Afghanistan and El Salvador. 

Whereas there are guidelines from the CDC for clinicians caring for refugees, most undocumented immigrants will present to our healthcare facilities having received little to no standardized health screening. 

Dr. Kasten-Arias encouraged us to refer to these guidelines-- found here -- when caring for all recent immigrants. 

When caring for recent immigrants, there are specific areas to pay attention to, including vaccination history, travel history, environmental exposure, infectious disease screening, mental health, and sexual health screening.

Vaccination 

• Verify the validity of vaccine records (criteria for validity: name of vaccine, month and year of administration, recommended timeline)
• Which vaccines are due or need revaccination
• When records are missing, favor administration over serologic testing (risk of repeat is low)

Travel History

• country of origin
• countries along immigration journey
• any other recent travel

Environmental Exposures

• Lead screening recommended by CDC for all newly arrived refugees/immigrants
• special attention to lead (>3.5ug/dl) due to high prevalence among refugees, who may have increased risk due to nutritional deficiencies of iron/calcium/zinc
• special attention to young children, pregnant and breastfeeding patients
• common lead sources in immigrants: car batteries (used to keep warm during journey), glazed pottery, industrial emissions, lead paint, herbal supplements, gasoline, candies (esp tamarind)

Infectious Disease Screening

• HIV (age 13-64, AND children <13 if high risk and/or unknown maternal status)
• TB -- 85% of US cases is reactivation of latent TB in immigrants-- screen with TST/IGRA for all children over 2 and TST for <2
• Intestinal parasites: almost all immigrants, regardless of country of origin, are at risk for stronglyoides infection. Check O+P for anyone with unexplained eosinophilia on CBC
• Viral Hepatitis
• HBV, highest risk from specific geographic areas, including SE Asia, West Africa, some parts of Sub-Saharan Africa
• CDC recommends screening ALL adults for HBV if not previously screening, children <18 if not completely vaccinated and no previous testing, all pregnant people regardless of previous vaccination
• Offer HBV vaccine to unvaccinated
• HCV screening for all adults, consider for unaccompanied minors and children w/risk factors

An excellent resource for refugees/recent immigrants is CareRef (from Minnesota): https://careref.web.health.state.mn.us/, which compiles CDC recommendations into an easy to use form and helps clinicians guide screening assessments. 

Mental health screening tool for refugees/newly arrived immigrants: https://www.cdc.gov/immigrant-refugee-health/hcp/domestic-guidance/mental-health.html

Sexual Health screening: 60% of women/girls experience sexual assault on journey to the border (Amnesty International 2010)

• CDC recommends contraception counseling, STI screening, family planning services
• pregnancy test for all refugees
• inform patients of confidential services for teens (>12 in CA)
• female genital cutting: https://www.cdc.gov/immigrant-refugee-health/hcp/domestic-guidance/sexual-and-reproductive-health.html
  
  

Screening Labs for initial visit:

Political Context and Advocacy Resources

We are all aware of the current political context with direct attacks by the federal administration on immigrant populations. In January 2025, the administration removed historical protections that protected immigration enforcement in hospitals, clinics, schools and places of worship.

 In March of 2025, The Physicians for Human Rights (PHR) released a document specifically for healthcare providers titled Health Care and US Immigration Enforcement: What Providers Need to Know

What can we do as healthcare providers?

• Proactively reassure patients
• Do not ask about immigration status unless required (we are NOT required in California)
• in states where you are required, you can inform patients that while we are required to ask, they are not required to respond
• Monitor and address rumors
• Share Know Your Rights information
• regardless of status, all patients have right to privacy, emergency care, and equal protection
• Ensure institutional preparedness protections against immigration enforcement
• right to remain silent (while immigration officials can enter any public space and question anyone, those being questioned have the right to remain silent and not respond to those questions)
• plain view: officers can have access to anything in plain view BUT cannot move things to get information (e.g. keep health records out of sight)
• warrants must be signed by a judge, have an individual's name on it, state the site at which it will served and accurate dates
• we are permitted to document and/or video any encounter with immigration officials
  
  
  

Northbay Rapid Response Network: https://www.northbayop.org/nbrrn

Additional resources:

Asylum Medicine Initiative

Physician for Human Rights Asylum resources

Doctors for Immigrants

Immigrant Legal Resource Center

ACLU for Healthcare Providers
Know Your Rights (for patients)

We Have Rights Campaign (for patients)

Practicing Changing OB Updates in 2024-25 (Watson, 4/23/2025)

 A recording of this presentation is available HERE.

***

Thanks to Dr. Hannah Watson, our interim Maternity Care Director at the Santa Rosa Family Medicine Residency, for an excellent talk on 2024-2025 OB Updates. She covered five studies recently published, which suggested some practice changes in the care of OB/Gyn patients. I love looking at recent literature to either reinforce our current practice or to update in real time what we do clinically. 

She also toured us through some beautiful wildflowers!

Here are my take home pearls:

1) VTE prophylaxis in patients after c-section (while hospitalized) may not change outcomes. 

In this retrospective cohort study of patients who received VTE ppx vs. those who didn't, 0.31% vs 0.08% (not statistically significant) developed VTE; 6.7% vs. 1.7% were readmitted, 3% vs 1% wound complications.

Bruno AM, Sandoval GJ, et al Postpartum pharmacologic thromboprophylaxis and complications in a US cohort. Am J Obstet Gynecol. 2024 Jul;231(1):128.e1-128.e11. doi: 10.1016/j.ajog.2023.11.013. Epub 2024 Feb 12. PMID: 38346912; PMCID: PMC11194157.

2) While antepartum betamethasone (for fetal lung maturity) has excellent evidence prior to 34 weeks EGS, in patients who deliver at 34-36 weeks, the positive impact of maternal steroids varies based on gestational age AND mode of delivery (LTCS vs. vaginal). 

In this secondary analysis of the 2017 Antenatal Later Preterm Steroids (ALPS) Trial, 7ounger gestational age and surgical delivery confer greater benefit of steroids. Of note, GDM patients were excluded from the ALPS trial.

Clapp MA, Li S, Cohen JL, Gyamfi-Bannerman C,  et al Betamethasone Exposure and Neonatal Respiratory Morbidity Among Late Preterm Births by Planned Mode of Delivery and Gestational Age. Obstet Gynecol. 2024 Dec 1;144(6):747-754. doi 10.1097/AOG.0000000000005756. Epub 2024 Oct 10. PMID: 39388700.

3) Pregnant patient with GDM may benefit with improved glucose control from split dosing their long acting (i.e. glargine) insulin when using over 20-30 units per day. Also injecting prandial insulin 20-30 minutes BEFORE eating improves glycemic control. 

Valent AM, Barbour LA. Insulin Management for Gestational and Type 2 Diabetes in Pregnancy. Obstet Gynecol. 2024 Nov 1;144(5):633-647. doi: 10.1097/AOG.0000000000005640. Epub 2024 Jun 13. PMID: 38870526.

4) Concurrent partner treatment (oral metronidazole and topical clindamycin) for patients with bacterial vaginosis (BV) reduces risk of recurrence of BV by 50% at 12 weeks. 

Recurrence rates of BV were still high: 63% at 12 weeks in the control group (no partner treatment) and 35% in the partner treatment group.

https://www.nejm.org/doi/full/10.1056/NEJMoa2405404

5) The Jada (aspiration system) demonstrates equivalent outcomes to the Bakri (balloon system) for post partum hemorrhage management.

Of note, Dr. Watson says that both she and patients generally prefer the Jada system, which generally stays in for one hour; whereas the Bakri requires traction for up to 12 hours. Evidence shows either system is better the sooner it is placed.

Shields, Laurence E. MD; Klein, Catherine MSN, RN et al Effectiveness of the Intrauterine Balloon Tamponade Compared With an Intrauterine, Vacuum-Induced, Hemorrhage-Control Device for Postpartum Hemorrhage. Obstetrics & Gynecology 145(1):p 65-71, January 2025. | DOI: 10.1097/AOG.0000000000005770

Options for Menstrual Suppression (Mak, 4/16/25)

 A recording of this presentation is available HERE.  

Thanks to Dr. Ray Mak for a good refresher on menstrual suppression. A reminder from Dr. Mak up front that there are varied reasons that people with a uterus prefer to suppress their menstruation -- from personal preference to medical indications, and we can and should know how to counsel them on how to safely do so.

Check out this table that outlines some of the reasons for menstrual suppression. Not included in the table are financial reasons (people spend $6000-$18,000 over their lifetime for menstrual products) or cancer risk reduction. 

Patient preference		Challenges with menstrual hygiene	Intellectual or developmental delay Limited dexterity or mobility
Gynecologic	Dysmenorrhea Endometriosis-related pain and bleeding Menorrhagia PMS Abnormal uterine bleeding	Work or social indications	Military deployment or space travel Athletes Camping or wilderness experience
Hematologic	Anemia Coagulation disorder Malignancy Chemotherapy	Other conditions worsened by menses	Irritable bowel syndrome Asthma Postural tachycardia syndrome Migraines

Combined oral contraceptives

The most commonly accepted and practices way to ensure menstrual suppression comes via continuous Combined oral contraceptives (COCPS)

-efficacy is 49%, 68% and 88% are 2, 6 and 12 cycles respectively

-monophasic OCPs are preferred 

-breakthrough bleeding (BTB) is the most common side effect and decreases with time

-lower estrogen levels in OCPs is associated with more BTB

-a hormone free break of 3-4 days is usually sufficient to manage BTB

-see two images below from the AAFP with guidelines on management of BTB

 

Additionally, menstrual suppression can occur using alternative contraceptive modes, including:

• vaginal ring (skipping ring-free week)>> amenorrhea 89% at 6 months, BTB more common early and diminishes with time (NSAIDs may help, no studies on adding estrogen)
• contraceptive patch (skipping patch-free week), not as well studied, no long term data, higher estrogen exposure, similar issues with BTB
• hormonal IUD (Mirena, Liletta)>> amenorrhea 50% at 1 year, 60% at 5 years; lower dose IUD not effective at attaining amenorrhea, can uses NSAID/estrogen or OCPs for BTB
• depo provera injections>> amenorrhea 50-75% at 1 year, increases with prolonged use; concerns about decreased bone density over time, also weight gain/mood changes. For BTB: NSAID, estrogen, cOCPs, decreasing injection interval (e.g. 2 months)
• etonogestrel implant>> 22% amenorrhea at 1 year, improved with prolonged use, irregular BTB is common

Aside from using contraceptive methods to induce menstrual suppression, other medications can be used, including:

• norethindrone acetate 5mg daily, not approved for contraception>> 76% amenorrhea at 2 years, can titrate up to 15mg daily (for BTB), different than norethindrone mini-pill (0.35)
• testosterone therapy for trans and gender diverse patients >> testosterone therapy usually suppresses by 3-6 months, transmen generally prefer to avoid estrogen  (because of desire for masculinization)
• GnRH agonists (puberty blockers), fast onset 4-6 weeks, high efficacy 96%, no increased prothrombotic use (often used in oncologic patients)
• Danazol

Menstrual suppression considerations for people with disabilities:

• can they swallow pills?
• can they tolerate invasive procedure?
• caution: bone density, weight gain, VTE risk in pts with decrease mobility at baseline
• scheduled withdrawal bleeding may be preferred over random BTB

Don't forget this chart:

Childhood Immunization (Bernard-Pearl, 4/9/2025)

  A recording of this presentation is available HERE.  

Please check back for a summary soon!

Let's Talk about Wound (Care) (Cardenas, 4/2/2025)

 A recording of this presentation is available HERE. 

Please check back for a summary soon!

Trauma Informed Care (Lund, 3/26/2025)

  A recording of this presentation is available HERE. 

Thanks so much to Dr. Erin Lund for a very impactful presentation this week on Trauma Informed Care. I have to confess that I have seen this presentation (or a previous version) before, but I DO need to hear and rehear and rehear this topic. 

If you remember nothing else, take pearl in: In our daily work should use "universal trauma principles" with ALL patients and then add "extra carefuly trauma informed care" with those whom we KNOW have had extra trauma. 

This includes things like asking for consent, empowering patients over their own bodies and histories, and resisting retraumatization.

I love/hate this image she shared, reminding us of the context of trauma that extends far beyond a person's individual experience. The medical trauma many of our patients have experienced primes them to respond in particular ways to our care provision, and we need to be prepared, but the collective and structural trauma is also ever present.

© Lewis-O’Connor, A. 2015 © Rittenberg, E 2015 © Grossman, S. 2015 UPDATED, April 2020, Feb 2022

Trauma abounds. 

Many of us are well-versed in the original Adverse Childhood Events (ACES) study, which found that 61.7% of CA adults had experienced at least one ACE, and 1 in 6 (16%) had experienced 4+ ACES. You can see the most common ACEs in the image below.

But trauma doesn't end in childhood. Adult traumatic experiences are also common; these include: intimate partner violence, gun violence, sexual assault, incarceration, birth trauma, accidents, racism, sudden loss of a loved one, and more. 

The actual "traumatic experience or incident" matters much less than how we respond to the trauma. What are our resources? Do we have resilience? What are our protective patterns? Do we have time to recover?

The image below is a schematic of a stress trigger, the natural response, and then what follows. Note the time of calming down, depletion and recentering. If we have the tools to pass through these stages, we can recover from the trigger. If not, we may not be able to. Traumatic experiences can lead to developing toxic stress physiology. And repeated stress can impact our neurodevelopment, interfering with executive function

www.dovetaillearning.org

Toxic Stress and Caring Adults - KABOOM!

 
A local non-profit does trainings/workshops to promote resilience. In their workshops, they teach us that our protective patterns, which we develop over time, can be helpful and keep us safe. But when overused or used in incorrect situations, they can be harmful, self-destructive, and inhibit connection with others. Those patterns are seen in the slide below:

SAMSHA (2021) says that to be trauma-informed we must 1) Realize the widespread impact of trauma and understand potential for recovery 2) Recognize the signs/symptoms of trauma 3) Respond by integrating this knowledge about trauma into policies and procedures and practices and 4) Seek to active Resist retraumatization. 

We can create a safe context, restore power, value individuals. We can use universal trauma precautions and stay patient-centered. Being trauma-informed in the medical setting involves empowering patients, giving choice when we can, collaborating, offering safety and trustworthiness. In addition, get curious, learn the back story, listen to patients' fears. Ask yourself and the patient, "How can we help you get through this?"

Resilience is protective. I very much recommend you listen to Dr. Lund's presentation, where she goes on to really talk about heartfelt listening, growing empathy to connect, not defining people by their trauma, and making a real difference through trauma-informed care. 

She ended her presentation with a seminal paper on Trauma informed care in the ED from Ashworth et al (2023). A link to that paper and very helpful tables is available HERE. 

Pediatric Ophthalmology (Qureshi, 3/19/25)

 A recording of this presentation is available HERE. 

My notes:

In pediatric patients, any condition that affects the amount of light passing through the eye will negatively affect the brain's ability to learn and see and result in permanent vision loss. 

Therefore, it is essential to treat pediatric eye disorders as quickly as possible!!

Common causes of childhood blindness, worldwide

• corneal scarring
• vitamin A deficiency
• measles
• opthalmia neonatorum
• harmful eye practices
• infective corneal ulcers
• congenital cataracts
• uncorrected refractive errors
• retinopathy of prematurity
• congenital glaucoma

WHO estimates 19 million visually impaired children worldwide, 1.4 million preventable blindness

Common pediatric eye disorders

• Amblyopia: a decrease in visual development that occurs when the brain doesn't get visual stimulation from the eyes (one or both eye send distorted image to brain, even when glasses are use). Only children get amblyopia, can result in permanent vision loss if not treated in child. Most common cause of vision loss in adults 20-70 is untreated amblyopia
• refractive amblyopia is treatable with glasses/patching
• patch the good eye, let the bad eye function, it works! but does not fix strabismus
• alternatively, drop of atropine in the good eye, to allow bad eye to see better (limits vision in good eye to a certain amount)
• deprivation amblyopia: if you have cataract or congenital ptosis blocking the pupil, very bad for visual development (poor prognosis within even 6 weeks, e.g. cataract, corneal ulcer, congenital ptosis)
• the primary care physician detects amblyopia (e.g. red light reflex), ophthalmology treats it
• asymmetric red light reflex>> urgent eval < 6 weeks of age
• Strabismus: ocular misalignment, "to squint or look obliquely", affects 4% of children <6 years, 30-50% results in reversible amblyopia (vision loss)
• strabismus testing: light reflex is the key (see image below)
• pseudostrabismus: looks like esotropia but light reflex is centered on the pupils (common in kids of Asian descent)
• surgical repair

• Congenital Cataracts: 1/3 hereditary, 1/3 associated with other disorder, 1/3 idiopathic
• must remove within 3 months to prevent irreversible vision loss
• Congenital Ptosis: must be able to see pupil, if kid is using a chin up position, vision is not a threat (ptosis is there, but vision is safe) 
  
  
  
• Horner Syndrome: when you see ptosis, check the pupils. The ptotic eye (SNS innervates the eyelid mm but also the iris dilator), if pupil assymetry with ptosis, patient needs brain/neck/upper chest imaging to follow nerve plexus to make sure there is no problem along the plexus causing the ptosis (e.g. tumor)
• Nevus of Ota: low percentage develop glaucoma (see R eye below, grey in sclera and skin)
• 
• Congenital Glaucoma: enlarged cornea, tearing eyes, spasmodic to light, can develop serious vison loss, need urgent treatment. Very different than an adult. In a kid you should be able to see swollen cornea,  almost like a corneal ulcer or maybe like one eye is bigger than the other. Should be referred urgently

• Retinoblastoma of childhood 
• most common ocular tumor or childhood
• usual onset < 4 years
• 25% present with strabismus
• treatment: radiation, chemo, possibly enucleation
• require systemic work up, including r/o pineal gland and bone tumors
• 
  
  
  
• Red eyes
• Nasolacrimal duct obstruction is very common, usually presents as tearing, common, 5% of newborns, 
• no rush to refer >>90% regress by 12 months (95% by 18 months)
• surgical treatment occurs 18-24 months w/nasolacrimal probe
• Dacryocystocoele (image below): within first few weeks of life, infection and bump w/preseptal cellulitis due to imperforate valve. Have to treat preseptal cellulitis with IV abx and then sedate and probe. It looks better after abx butu if you don't create the passage, it will recur.
  
  
  
• Blepharitis: Very common, redness in conjunctiva and redness in eyelids>> treat the eyelids (warm compresses, abx drops despite no infection> glands work and eyes work better). Can also have stye. Erythromycin ointment doesn't work, but Maxitrol drops do work.

• Neonatal conjunctivitis: neonatal gonorrhea (very violent, first day of life), chlamydia, chemical, HSV (4-5 weeks of life).
• need systemic treatment AND ointment
• Allergic conjunctivitis: itchy red eyes, papillae, zaditor drops OR systemic allergy treatment, temporary steroids okay w/taper if really bad
• vernal conjunctivitis is severe form of allergic, can lead to shield ulcers, giant papillae, often in young men
• Styes: obstruction of meibomian glands, very common 
• hordoleum is a blocked gland
• chalazion is the more chronic granulomatous form
• warm compresses, maxitrol (neomycin/polymyxin/dexamethasone) ointment, only if superinfection can consider antibiotic
• 

Pediatric Vision Screening

Direct visual acuity screening is gold standard

• Start screening age 3/4 w/HOTV or heart/house/square tools for refractive problems

(Tumbling E hard to do with young kids)

• Age 4-5, use HOTV card but can use "match card", looking for 20/40 vision (doesn't have to be better), one eye should NOT be way better than the other> this should trigger referral
• Age 5+, looking for 20/30 or better, move to Sloan Letters and repeat  q1-2 years

Phenobarbital for Severe Alcohol Withdrawal Syndrome (Aguilar & Bowen 3/12/2025)

 A recording of this presentation is available HERE. 

My notes:

• 10.9% of US adults have alcohol use disorder (AUD) at some point in their lifetime (!!)
• AUD costs the US $249 billion/year
• 178,000 excess deaths due to AUD in the US 2021
• Compared to opioids, higher rates of alcohol use, misuse, ED visits, and deaths see below)

Alcohol Withdrawal Syndrome (AWS)

• 500,000/year episodes of AWS requiring pharmacological treatment
• 5-20% of people admitted to the hospital have AWS
• highest risk of seizures in first 1-2 days of AWS, DTs 4-6 days with looooooooong tail
• Reminder of difference between hallucinosis vs. DTs (autonomic instability)

Neuropharmacology of Alcohol

Dopamine>> reward>> addiction

GABA agonism during intoxication>> sedation

Chronic use>> GABA downregulation, Glutamate upregulation

Lots of other neurotransmitters involved: opiate R, serotonin R, cannabinoid R, etc

When we take away alcohol (after chronic use), our GABA system is completely depleted, and our glutamate is "going wild"

Phenobarbital is a barbiturate

• GABA agonism, suppresses glutamate
• PO>> onset 60 minutes, IV>> onset 5 minutes
• metabolized in the liver, excreted renally
• 1/2 life ~79 hours (range 53-118 hours)
• this prolonged half life allows for a built in taper
• has a predictable pharmacokinetics at 10mg/kg (deal body weight), though no RCTs that study "ideal drug level" for AWS
• no documented barbiturate resistant alcohol withdrawal

Traditional treatment of AWS is with benzodiazepines. We know benzos can cause paradoxical agitation and delirium. In addition, a lack of endogenous GABA in chronic alcohol use can make benzos less useful.

What does the current  literature say about Phenobarbital vs benzos?

• Retrospective cohort study, 42-bed ICU, 120 participants (2018, Am J of Critical Care)
•  shorter ICU stays (2.4 vs 4.4), shorter hospital stays (4.3 vs 6.9).  lower rate of mechanical ventilation (2% vs 23%), fewer adjunctives including precedex (7% vs 28%)
• RCT with ED pts requiring admission – single dose phenobarb vs symptom-based BZD, 102 participants (2013 Journal of Emergency Medicine)
• decreased ICU admission rates (8% vs 25%), decreased BZD use
• Retrospective cohort over 2 years, 606 participants (2021, Cureus)
• shorter hospital stay (2.8 vs 3.6), lower all-cause 30-day readmission (11%  vs 19%), fewer 30-day ED visits
• 2 different Metanalyses (2021) findings: may shorten hospital LOS, unclear if shortens ICU LOS but does decrease ICU admission, benzo sparing, may result in less intubation

Some suggestion that we should move away from CIWA for scoring AWS. One proposed alternative is RASS scoring, which should be familiar to people who work in ICUs

Proposed Phenobarbital Protocol DRAFT

Notes:

• For HIGH risk patients (CIWA>20 OR CIWA>16 with Risk factors)
• 10-12 mg/kg (IDEAL body weight) loading dose
• Use ideal body weight calculator (MD Calc)
• should happen in monitored setting (ED vs. ICU) only
• For patients who may be at lower risk for AWS, consider lower dose than the loading dose (e.g. 130mg, 260mg IV/IM) q30 minutes-1 hour
• Patients who have already been treated with benzos CAN receive phenobarbital but should be lower dose (due to risks of sedation)

References:

1. SAMHSA Center for Behavioral Health Statistics and Quality. (2022). National Survey on Drug Use and Health (Table 5.9A—Alcohol use disorder in past year: among people aged 12 or older; by age group and demographic characteristics, numbers in thousands, 2021 and 2022, Issue. https://www.samhsa.gov/data/sites/ default/files/ reports/ rpt42728/NSDUHDetailedTabs2022/NSDUHDetailedTabs2022/NSDUHDetTabsSect5pe2022.htm#tab5.9a  

2. Centers for Disease Control and Prevention. (February 29, 2024). Excessive Alcohol Deaths. Retrieved April 1 from https://www.cdc.gov/alcohol/features/excessive-alcohol-deaths.html#:~:text=About%20178%2C000%20people%20die%20from,or%20488%20deaths%20per%20day

3. Fixed-Dose Phenobarbital Versus As-Needed Benzodiazepines for the Management of Alcohol Withdrawal in Acute Care General Internal Medicine https://pubmed.ncbi.nlm.nih.gov/38151248/#:~:text=There%20was%20no%20difference%20in,%25%2C%20P%20%3D%200.03).

4. National Institute on Alcohol Abuse and Alcoholism. (2024). Alcohol-related emergencies and deaths in the United States. Retrieved April 1 from https://www.niaaa.nih.gov/alcohols-effects-health/alcohol-topics/alcohol-facts-and-statistics/alcohol-related-emergencies-and-deaths-united-states

5. Maldonado, J. R. (2017). Novel Algorithms for the Prophylaxis and Management of Alcohol Withdrawal Syndromes-Beyond Benzodiazepines. Crit Care Clin, 33(3), 559-599. 

6. Tidwell, W. P., Thomas, T. L., Pouliot, J. D., Canonico, A. E., & Webber, A. J. (2018). Treatment of Alcohol Withdrawal Syndrome: Phenobarbital vs CIWA-Ar Protocol. Am J Crit Care, 27(6), 454-460. 

7. Rosenson, J., Clements, C., Simon, B., Vieaux, J., Graffman, S., Vahidnia, F., . . . Alter, H. (2013). Phenobarbital for Acute Alcohol Withdrawal: A Prospective Randomized Double-blind Placebo-controlled Study. The Journal of Emergency Medicine, 44(3), 592-598.e592. 

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