Pharmacological Treatment for Alcohol Use Disorder

The American Psychiatry Association has just released new practice guidelines for the pharmacological treatment of patients with alcohol use disorder. For the full guidelines, click here.  In this guideline, the use of these 5 agents have been discussed: naltrexone, acamprosate, disulfiram, topiramate and gabapentin.

First line treatment options include both naltrexone and acamprosate as both have the most available clinical evidence for either a reduction in drinking days or a reduced likelihood of returning to drinking.

  • Naltrexone is a mu-opioid receptor antagonist which is indicated for both alcohol use disorder and opioid use disorder.
    • Oral tablet: Usual dose is 50mg po daily (up to 100mg/day.) Can be slowly titrated to minimize GI side effects with 25mg po daily initially.
    • Given it can cause hepatic toxicities, should monitor for LFTs pre-treatment as well as for the treatment duration
    • must abstinent from opioids at least 7-14 days prior to prevent withdrawal symptoms.
    • In Ontario, naltrexone may be covered via the Exceptional Access Program for alcohol dependence therapy.
  • Acamprosate is a glutamate receptor modulator which is indicated for alcohol use disorder
    • Dosing is 666mg po TID; for individuals with CrCL between 30-50mL/min, dose reduction to 333mg po TID; contraindication if CrCl <30ml/min
    • Eliminated renally; should monitor SCr pre-treatment as well as for the treatment duration.
    • In Ontario, naltrexone may be covered via the Exceptional Access Program for alcohol dependence therapy.

In United States, I presume disulfiram is still available (it isn’t available anymore in Canada) so the practice guideline recommends offering it to patients with moderate to severe alcohol use disorder who prefer disulfiram or intolerant to naltrexone or acamprosate.  They must also be capable to understand the risks of alcohol consumption while taking disulfiram.

  • Disulfiram is an inhibitor of aldehyde dehydrogenase and is indicated for alcohol use disorder
    • Dosing involves starting 1st dose 12 hours after last drink, 500mg po qam for 1-2 weeks, then 250mg po qam.
    • Need to monitor LFTs and baseline ECGs
    • Contraindicated in recent myocardial infarction, coronary artery disease and history of seizure
    • Must be completely abstinent from alcohol
    • Disulfiram is not available in Canada.

Alternative options also include topiramate and gabapentin. although the evidence is not as strong with these two agents. They may be offered to patients who cannot tolerate naltrexone, acamprosate or disulfiram.

  • Topiramate is an antiepileptic which has demonstrated a reduction in drinks per drinking day, % of heavy or any drinking days as well as reduction in the subjective experience of “craving”.
    • Usual Dose ranges from 200-300mg per day. May want to titrate dose gradually to minimize side effects.
  • Gabapentin is also an antiepileptic shown to increase rate of abstinence and reduction in heavy drink days.
    • Dosing ranges from 900-1200mg/day.  Dose related sedation is a commonly reported side effect.

Other important considerations:

  • Antidepressant medications are not recommended for treatment of alcohol use disorder unless they are indicated for other co-occurring disorders.
  • Similarly, benzodiazepines are not recommended for treatment of alcohol use disorder unless there are acute withdrawal symptoms or indicated for co-occurring disorders
  • For women who are pregnant or breastfeeding, it is recommended that pharmacological agents not be used for alcohol use disorder, unless needed for acute withdrawal symptoms (with benzodiazepines) or therapy needed for other co-occurring disorders.

Hope this quick snapshot of the guideline is helpful. Thank you for reading my post.

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drugopinions

My name is Cynthia Leung and I am a practicing pharmacist in Kingston Ontario, Canada. This blog is for me to share my ideas, opinions and perspectives on how medications are used in our health care system. Note that these posts are my own opinions and do not represent the opinions of my current or former employers and / or organizations that I may belong to. Any possible case scenarios described in my posts would be modified to maintain patient confidentiality. This blog is not a platform for professional advise for patients or health care providers and the content is not meant to support any clinical decisions or replace professional opinions. Also the images are either taken or created by the author, or adapted with permission. I hope you will enjoy reading my posts!

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