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Barbiturates are a category of sedative-hypnotic medications used for treating seizure disorders, neonatal withdrawal, insomnia, preoperative anxiety, and the induction of coma to address increased intracranial pressure (ICP). In addition, these medications are also helpful for inducing anesthesia. Thiopental, introduced in 1934 for general anesthesia induction, served as the primary intravenous anesthetic induction agent until propofol replaced it. Barbiturates approved by the US Food and Drug Administration (FDA) for clinical use include phenobarbital, methohexital, butalbital, pentobarbital, primidone, and amobarbital. Various barbiturates have been either discontinued or substituted with benzodiazepines. Given the prevalence of drug-drug interactions in specific populations, the collaborative efforts of the interprofessional team, including primary care, emergency medicine, and/or specialists, are essential for devising the most effective management plan based on best practices. This activity outlines the indications, mechanism of action, pharmacokinetics, administration, adverse effects, contraindications, and toxicology of certain barbiturates. Clinicians involved will examine the monitoring parameters encompassing a wide range of physiological considerations when employing barbiturates in the clinical setting, along with crucial aspects in the care management of patients using these substances. Objectives: Identify the appropriate indications for barbiturate use in various clinical scenarios, such as seizure disorders, neonatal withdrawal, insomnia, and induction of anesthesia. Implement safe and evidence-based practices when administering barbiturates, including proper dosing, monitoring, and adjusting for individual patient needs. Assess patients regularly for signs of adverse effects and monitor therapeutic efficacy, adapting treatment plans as necessary. Collaborate with the interprofessional healthcare team, including primary care, emergency medicine, and specialists, to develop comprehensive management plans for patients using barbiturates. Access free multiple choice questions on this topic.

Signs and Symptoms of Overdose Acute barbiturate toxicity can arise from intentional or unintentional overdose. Barbiturates, with a history of abuse, were associated with 8469 cases of poisoning, according to data from the New York City Health Department, spanning the period from 1957 through 1963.[73] Overdosage of phenobarbital symptoms includes CNS depression, respiratory failure, and hemodynamic instability. Management of Overdose No specific antidote exists for barbiturates, and overdose treatment includes supportive care and urinary alkalinization.[71] A systematic review demonstrates the efficacy of multiple-dose activated charcoal for phenobarbital and primidone overdose. Hemodialysis and haemoperfusion may be considered in patients with life-threatening barbiturate toxicity.[74] Extracorporeal clearance with dialysis can augment drug elimination in cases of severe butalbital overdose.[75] During recovery, patients with chronic barbiturate misuse can present with seizures and autonomic instability.[15]

Barbiturates have historically been a widely prescribed class of drugs in outpatient and inpatient settings. Barbiturates are classified as controlled substances, necessitating adherence to all DEA prescription requirements. The prescription drug monitoring program serves to identify potential misuse and abuse.[76] Benzodiazepines have primarily replaced them when used for anti-anxiety or insomnia. The utilization of barbiturates for IV anesthesia has significantly diminished for the following 2 primary reasons: After 2011, leading manufacturers ceased the production of thiopental or methohexital. Propofol has emerged as the favored routine IV anesthetic induction agent owing to its ready availability, rapid onset, and quick offset. Phenobarbital continues to be used as a second-line antiepileptic drug in the United States and has frequent use in low-resource countries as a first-line drug due to its low cost. The systematic review and meta-analysis concluded that phenobarbital is an effective tool in the management of alcohol withdrawal syndrome in an ICU setting.[77] All healthcare professionals, including physicians and nurse practitioners who prescribe these agents, must be fully aware of the adverse drug reactions, misuse, drug-drug interactions, and the potential to develop physical dependence. When barbiturates are used in anesthesia, supervision by anesthetics and certified registered nurse anesthetists is necessary. Movement disorder specialists should oversee the use of primidone for essential tremors. Given the potential for severe adverse events, including death, a pharmacist should verify the dosing and perform a thorough medication reconciliation to ensure no drug interactions, particularly additive CNS-depressing effects. The healthcare team must be proficient in resuscitating a patient in the event of an overdose, often necessitating MICU-level care and consultation with a critical care clinician. In cases of severe overdose, consultation with a toxicologist is advisable. A psychiatrist should be consulted once the patient has recovered in case of an overdose. The prescription of barbiturates and subsequent monitoring necessitates an interprofessional team approach, fostering collaboration across various disciplines to achieve optimal patient outcomes in barbiturate therapy.