Disulfiram can be offered to motivated patients with alcohol use disorder who have a clear goal of achieving abstinence. It is con- traindicated in patients who are active alcohol users, so patients must understand the risks of consuming alcohol while taking di- sulfiram. Topiramate or gabapentin can also be offered as second- line agents for patients who wish to reduce or eliminate alcohol consumption, have not responded to naltrexone and acampro- sate, or prefer to use these agents (Reus et al., 2018). Naltrexone is an opioid receptor antagonist frequently used to treat opioid and alcohol abuse. It works by blocking mu opioid receptors and preventing binding, thus reducing the pleasurable effects of opioids. It reduces alcohol consumption by modula- tion of opioid systems, which reduces the reinforcing effects of alcohol. Naltrexone use has been associated with a reduction in the number of drinking days and reduced likelihood of returning to drinking, and it is also thought to decrease cravings. It is the drug of choice in patients with concomitant opioid use disorder, since it is approved to treat both conditions. Patients should not be actively using opioids when naltrexone is started, since it can inhibit the effects of opioids and lead to noncompliance (Kim et al., 2018; Reus et al., 2018). Medications Naltrexone Naltrexone is available in oral tablets and an intramuscular formu- lation (Vivitrol), which is administered every 4 weeks. The choice between dosage forms is based on patient preference; some pa- tients show better adherence to daily dosages, while others are more willing to attend monthly visits for injections. Typically, it is preferable to start intramuscular naltrexone to ensure adher- ence, though starting with oral tablets may be more appropriate in some cases, to allow monitoring of liver enzymes and side ef- fects before committing to a longer course of treatment (Kim et al., 2018; Reus et al., 2018). Intramuscular injections of naltrexone are given at a dose of 380 mg into the gluteal muscle every 4 weeks. Adverse reactions as- sociated with intramuscular naltrexone include nausea, vomiting, diarrhea, fatigue, decreased appetite, and injection site reactions ranging from injection site pain to cellulitis and abscesses. Pa- tients should be encouraged to report injection site reactions to their provider to prevent them from developing into more serious skin conditions (Kim et al., 2018; Reus et al., 2018). Oral naltrexone is typically started at 50 mg per day, though some studies have used up to 100 mg per day or started with 25 mg per day for a few days and increased to 50 mg once the lower dose is tolerated well. Side effects with oral naltrexone are similar to those with intramuscular naltrexone and include headache, dizzi- ness, nausea, vomiting, diarrhea, and abdominal pain. These tend to subside with regular use. Gastrointestinal side effects tend to be more common in women than in men (Kim et al., 2018; Reus et al., 2018). Liver enzymes should be monitored within several weeks of start- ing either oral or injectable naltrexone, and then should be moni- tored every 6 months during continued treatment. Healthcare consideration: Patients with hepatic failure or acute hepatitis should avoid using naltrexone. Naltrexone is not rec- ommended for use in patients taking opioids, since naltrexone will decrease the effectiveness of opioids. Patients should be abstinent from opioids for 7 to 14 days prior to starting naltrex- one, depending on the half-life of the opioid consumed (Kim et al., 2018; Reus et al., 2018). Acamprosate Acamprosate may be prescribed to help patients recovering from alcohol abuse or dependence to help decrease alcohol cravings and relieve emotional discomfort. Acamprosate’s action in alcohol use disorder is through modulating excitatory glutamate neuro- transmission and enhancing GABA, which may help reduce alco- hol cravings. It has been shown to significantly reduce the risk of returning to alcohol use after achieving abstinence and reducing
Psychosocial interventions are recommended for all patients with alcohol use disorder. These can include alcohol counseling, moti- vational interviewing, couples or family therapy, social services, or participation in a mutual help group. Psychosocial interventions can be effective to treat alcohol use disorder, but when used as monotherapy, as many as 70 percent of patients return to heavy drinking. Selection of psychosocial interventions should be made on a patient-specific basis (Hoffman & Weinhouse, 2021). the number of drinking days. It is an effective first-line alternative to naltrexone and is often chosen for patients taking opioids and those with severe liver disease. It is also a useful second-line treat- ment in patients who do not experience an adequate response to naltrexone (Kim et al., 2018; Reus et al., 2018). Dosing for acamprosate is 666-mg tablets three times daily. Pa- tients with moderate renal dysfunction, shown by a creatinine clearance of 30 to 50 mL/min, are recommended to begin at 333 mg three times daily. Lower dosing can also be considered for patients with a body weight less than 60 kg. Acamprosate is gen- erally well tolerated. Common side effects include nausea and diarrhea and, although rare, depression and suicidality. Renal function should be monitored. Acamprosate is contraindicated in those with creatinine clearance less than 30 mL/min. There are no known drug interactions. Health care providers should counsel patients on the importance of adherence to acamprosate to en- sure its effectiveness (Kim et al., 2018; Reus et al., 2018). Healthcare consideration: Choosing between naltrexone and acamprosate A number of factors can be considered when de- ciding between initiating naltrexone and acamprosate in a pa- tient with alcohol use disorder. These include available formula- tions, ease of administration, side effects, and presence of renal or hepatic disease. A large meta-analysis did not show a statisti- cally significant difference between acamprosate and naltrexone in the percent of patients with a return to drinking, percent of patients with a return to heavy drinking, or the number of drink- ing days. Therefore, naltrexone or acamprosate can be seen as an appropriate initial treatment for AUD, and patient-specific fac - tors should be utilized to determine the best choice for a given patient (Reus et al., 2018). Disulfiram Disulfiram is prescribed to help dissuade patients from drink - ing. Disulfiram works by inhibiting aldehyde dehydrogenase, the enzyme involved in metabolism of the primary metabolite of al- cohol, acetaldehyde. If alcohol is consumed in the presence of disulfiram, acetaldehyde levels increase to toxic levels, creating very unpleasant side effects that include nausea, vomiting, flush - ing, headache, dyspnea, palpitations, lowered blood pressure, and sympathetic overactivity. Symptoms typically begin within 10 minutes of consuming alcohol, and the severity of the reaction is typically related to the amount of alcohol ingested. Symptoms can last for several hours or up to a day. 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 (Kim et al., 2018; Reus et al., 2018). Disulfiram is typically given in doses of 125 to 500 mg per day. Di - sulfiram should not be administered to patients who are currently drinking or intoxicated with alcohol. Patients must be clearly in- formed about the effects of the drug and give permission for its use. This treatment’s effectiveness depends on the patient’s coop- eration. 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 discontinua- tion. Adherence can be a significant issue with disulfiram use. En - listing the help of a family member, roommate, or other support person can help keep the patient accountable (Kim et al., 2018; Reus et al., 2018).
EliteLearning.com/Pharmacy
Book Code: RPUS3024
Page 7
Powered by FlippingBook