Some patients develop more severe reactions such as chest pain, seizures, confusion, headache, or severe vomiting; these require further evaluation to rule out alternative conditions such as myocardial infarction. 204,213 Disulfiram is typically given in doses of 125 to 500mg per day. Disulfiram should not be administered to patients who are currently drinking or intoxicated with alcohol. Patients must be clearly informed about the effects of the drug and give permission for its use; this treatment’s effectiveness depends on the patient’s cooperation. Patients should be educated on hidden forms of alcohol, such as that found in mouthwash, and that the medication can continue to exert its effects for up to 14 days after discontinuation. Adherence can be a significant issue with disulfiram use; enlisting the help of a family member, roommate, or other support person can help keep the patient accountable. 204,213 Disulfiram is often reserved for second line therapy in patients with alcohol use disorder. Naltrexone and acamprosate appear to have more evidence of benefits with their use, and disulfiram has a number of physiological consequences if alcohol relapse occurs. However, some patients who have a clear goal of abstinence prefer the accountability that disulfiram requires. Studies have not shown high-strength evidence on the benefits of disulfiram, but it appears to have a clear role in motivated patients. 204 Disulfiram is contraindicated in patients with psychosis, clinically significant coronary artery disease, and known hypersensitivities to the medication. When alcohol is avoided, disulfiram is generally well-tolerated, but side effects may include drowsiness, metallic taste and headache. Serious side effects are rare but can include psychosis and hepatitis. Patients should have a hepatic panel drawn a few weeks after initiating treatment and repeat every 6 months with continued treatment. Patients with seizure disorders should avoid disulfiram due to the potential for seizures when alcohol is consumed while taking disulfiram. 204,213 Drug interactions with disulfiram include the following: 213,214 ● Isoniazid: Can increase serum concentrations of isoniazid. Avoid concurrent use. ● Metronidazole: May cause psychotic reaction because of the increased effects of both disulfiram and metronidazole. Avoid concurrent use. ● Phenytoin: May increase toxic effect of phenytoin. Phenytoin levels must be carefully monitored, and dose adjusted as needed. ● Warfarin: Disulfiram can increase the concentration of warfarin; therapy adjustments may be required. An important counseling point for disulfiram is for the patient to avoid any type of alcohol-containing product, even mouthwashes and cough syrups. These products may cause the unwanted reactions if taken while using disulfiram. Patients should also be counseled that if they do drink alcohol, fatal hypotension can occur. Reactions with alcohol ingestion may occur up to two weeks after disulfiram is stopped. 204,213
Topiramate (Topamax) Topiramate is an anticonvulsant that affects voltage- dependent sodium channels, GABA transmission, and glutamate receptors. It has been found to reduce alcohol use in patients with alcohol use disorder and is the preferred second-line option in patients with seizure disorders. Some have shown that topiramate has mild to moderate effectiveness in reducing the percent of drinking days, reducing heavy drinking days, increasing abstinence, reducing cravings, and improving quality of life, but results have not been consistent in displaying these outcomes. 204,213 Topiramate is initiated at 25 mg daily and can be titrated up slowly over 8 weeks to a maximum dose of 300 mg per day; titration helps to minimize the risk of adverse effects. Adverse effects associated with topiramate include cognitive impairment, sedation, weight loss, gastrointestinal side effects, headache, fatigue, dizziness, depression, and paresthesias. Since weight loss occurs in 4 to 21% of patients, topiramate may be preferrable in obese patients. Some patients find the cognitive impairment associated with topiramate to be intolerable, as it affects word finding abilities and can impact psychosocial interactions. Rare but serious side effects include nephrolithiasis, acute angle-closure glaucoma, and metabolic acidosis. It may be beneficial to monitor renal function and cognitive status prior to initiation. 204,213,215 Gabapentin (Neurontin) Patients who previously failed first-line treatments can consider gabapentin for alcohol use disorder. Gabapentin is an anticonvulsant that is structurally similar to GABA and may modulate excitatory neurotransmitters in the brain; it can be used off- label for alcohol use disorder. Clinical trials showed that doses of 900 to 1800 mg per day have shown efficacy in reducing the percentage of heavy drinking days, increasing abstinence rates, reducing drinking frequency and quantity, and improving mood, cravings, and sleep. Common side effects associated with gabapentin include dizziness, drowsiness, fatigue. Gabapentin is primarily eliminated through the kidneys, and patients with renal impairment require dosage adjustments. There have been reports of addictive potential with gabapentin; providers should be alert to potential misuse. 204,216 Psychosocial Therapy Along with any of these medications, one or more psychosocial interventions are recommended, including cognitive behavioral therapy, behavioral couples therapy, community reinforcement or group therapy, motivational enhancement therapy, and 12-step programs While the quality of evidence supporting these interventions is low, they can modestly improve adherence, reduce alcohol consumption, and assist in recovery of patients with alcohol use disorder, particularly when used in combination with one another or with pharmacological therapy.
Book Code: CA23CME
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