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 AUD and is the preferred second-line option in patients with seizure disorders. Some research has 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 (Kim et al., 2018; Reus et al., 2018). Topiramate is initiated at 25 mg daily and can be titrated up slow- ly over 8 weeks to a maximum dose of 300 mg per day. Titra- tion helps to minimize the risk of adverse effects. Adverse effects associated with topiramate include cognitive impairment, seda- tion, weight loss, gastrointestinal side effects, headache, fatigue, dizziness, depression, and paresthesias. Since weight loss occurs in 4 to 21 percent of patients, topiramate may be preferrable in patients who are obese. Some patients find the cognitive impair - ment 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 (Holt, 2021; Kim et al., 2018; Reus et al., 2018). Gabapentin (Neurontin) Patients who previously failed first-line treatments can consider gabapentin for alcohol use disorder. Gabapentin is an anticonvul- sant that is structurally similar to GABA and may modulate excit- atory neurotransmitters in the brain. It can be used off-label for AUD. Clinical trials showed that doses of 900 to 1,800 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, drowsi- ness, and fatigue. Gabapentin is primarily eliminated through the kidneys, and patients with renal impairment require dosage ad- justments. There have been reports of addictive potential with ga- bapentin, so providers should be alert to potential misuse (Reus et al., 2018; U.S. Department of Veterans Affairs, 2021). of therapy sessions, such as self-monitoring, scheduled activities, thought recording, and interpersonal skill practice. Cognitive be- havioral therapy has been shown to be effective in patients with alcohol use disorders compared to minimal psychosocial interven- tions (U.S. Department of Veterans Affairs, 2021). The community reinforcement approach is a type of cognitive behavioral therapy that focuses on environmental factors that influence the patient’s behaviors. Environmental factors can be very influential on a patient’s addictive behavior, so this approach uses social, recreational, family, and occupational events to sup- port the patient in changing their behavior. This helps the patient develop healthy behaviors that allow a sober lifestyle to become more rewarding than one that involves alcohol use. Some forms of the community reinforcement approach provide incentives for positive behaviors, such as taking medication, attending treat- ment sessions, or abstinence (U.S. Department of Veterans Af- fairs, 2021). Behavioral couples therapy is useful for patients in relationships and focuses on reducing alcohol use and improving relationship satisfaction for both the patient and their partner. Shared activities and behavioral assignments are given to help increase positive feelings and communication between partners.
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 oc- curs. However, some patients who have a clear goal of abstinence prefer the accountability that disulfiram requires. Studies have not shown robust evidence on the benefits of disulfiram, but it ap - pears to have a clear role in motivated patients (Reus et al., 2018). Disulfiram is contraindicated in patients with psychosis, clinically significant coronary artery disease, and known hypersensitivities to the medication. When alcohol is avoided, disulfiram is gener - ally well-tolerated, but side effects may include drowsiness, me- tallic 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 it every 6 months with continued treatment. Patients with seizure disorders should avoid disulfiram because of the potential for sei - zures when alcohol is consumed while taking disulfiram (Kim et al., 2018; Reus et al., 2018). Drug interactions with disulfiram include the following (Kim et al., 2018; Stahl, 2020): ● 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 the toxic effect of phenytoin. Phe- nytoin levels must be carefully monitored, and adjust the dose 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 adverse reactions if taken while using disulfiram. Patients should also be counseled that if they do drink alcohol, fatal hypotension can occur. Reac- tions with alcohol ingestion may occur up to 2 weeks after disulfi - ram is stopped (Kim et al., 2018; Reus et al., 2018). Healthcare consideration: Patients should be educated on the importance of reading labels and looking for small amounts of alcohol that can be hidden in various products. Mouthwash, liq- uid medications, and vanilla extract are examples of daily items that contain alcohol and may cause a reaction when used with disulfiram (Holt, 2021). 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 con- sumption, and assist in the recovery of patients with alcohol use disorder, particularly when used in combination with one another or with pharmacological therapy. Psychosocial therapy may be particularly beneficial in patients with co-occurring mental health conditions such as anxiety or depression (U.S. Department of Vet- erans Affairs, 2021). Cognitive behavioral therapy (CBT) helps patients adjust their behavior and thinking related to alcohol use and encourages pa- tients to change other areas of life that are related to their alcohol use. Patients are taught to track activities and thinking in order to identify the consequences, such as alcohol use episodes and cravings. Then techniques are taught to help the patient change behaviors and thoughts that contribute to alcohol use in order to improve interpersonal functioning, mood, coping skills, and so- cial support. Treatment plans include structured practice outside
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