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Featured Clinical Topic-Psychiatry: APA develops Practice Guideline for the Pharmacological Treatment of Patients with Alcohol Use Disorder

22 Mar 2018 10:33 AM | Anonymous

Thi Dang, PharmD Candidate 2019: UMKC School of Pharmacy
Leigh Anne Nelson, PharmD, BCPP: UMKC School of Pharmacy

Alcohol Use Disorder (AUD) is a pattern of alcohol use that includes compulsive alcohol use, loss of control over alcohol intake, and having withdrawal symptoms when decreasing or ceasing alcohol intake. Alcohol effects on physical, psychological, and mental health can lead to many diseases and injury-related health conditions. In the United States, AUD is most common between ages 18 through 29 and overall, the rate of AUD is increasing. The Amercian Psychiatric Association (APA) developed a new practice guideline in 2018, which provides recommendations regarding appropriate use of medications for treatment of AUD, assessment to reduce the psychological and public health consequences from problematic alcohol use and guidelines to enhance the effectiveness of treatment. APA recommends appropriate pharmacotherapy to patients with AUD, including naltrexone, acamprosate, disulfiram, topiramate, and gabapentin. Additionally, the guideline cautions against use of certain medications, such as antidepressants and benzodiazepines.

Naltrexone is offered to patients with moderate to severe AUD or opioid use disorder to reduce alcohol consumption and help decrease cravings. The recommended starting dose of oral naltrexone is 50 mg daily and maximum is 100 mg daily. Common adverse events from oral naltrexone include abdominal pain, nausea, diarrhea, vomiting and dizziness. Overall, it is well tolerated. For long acting naltrexone, patients may consider naltrexone intramuscular (IM) injection. The recommended dose is 380 mg IM every 4 weeks. Associated side effects of intramuscular naltrexone include pain or induration at the injection site and increased potential for bleeding in patients who take anticoagulants. Because naltrexone reduces the efficacy of opioids for analgesia and elevates hepatic enzymes, APA recommends against using naltrexone as a treatment for AUD if patients also use opioids or anticipate the need for opioids in the near future. Naltrexone should also be avoided in patients with acute hepatitis or liver failure.

Acamprosate is recommended to treat patients with moderate to severe AUD and helps to reduce alcohol consumption. The recommended starting dose is 666mg three times daily. A common side effect is diarrhea. Overall, it is well tolerated. Acamprosate is excreted through kidneys, hence, serum creatine should be measured at baseline. Acamprosate is not recommended for patients who have severe renal impairment or when CrCl is less than 30 mL/min. In patients with mild to moderate renal impairment with CrCl between 30-50 mL/min, the acamprosate dose should be reduced. The main barrier of using acamprosate is the medication needs to be dosed three times a day.

Disulfiram is offered to patients with moderate to severe AUD, who are intolerant to naltrexone and acamprosate. It is not the first line of treatment. Disulfiram is appropriate only for patients who seek abstinence and are actively using alcohol or products containing alcohol. The usual recommended dose of disulfiram is 250 mg daily and common side effects include liver toxicity, tachycardia and QTC prolongation. Disulfiram is associated with several drug interactions that may limit its use and is not recommended in patients with seizure disorders. Ritonavir and other antiretroviral medications increase disulfiram levels through CYP450 3A4 and metronidazole can cause psychosis and confusion when combined with disulfiram. To help avoid possible drug interactions with disulfiram, patients should let healthcare providers or emergency personnel know that they are taking disulfiram.

Topiramate is recommended for patients with moderate to severe AUD, who are intolerant to naltrexone and acamprosate. The recommended starting dose is 200-300 mg daily. Common adverse events include weight loss, sedation, cognitive dysfunction and dizziness. Before starting topiramate as an initial treatment for AUD, it is appropriate to assess the patient’s cognitive status and renal function. In patients with renal impairment, the topiramate dose should be reduced.

Gabapentin helps to reduce the alcohol consumption and increases the rate of abstinence in patients with AUD. The recommened starting dose is between 900 to 1800 mg/day and associates with common adverse events include fatigue, insomina, and headache. In patients with renal impairment, the dose of gabapentin should be adjusted.

APA recommends against use of specific medications, including antidepressants and benzodiazepines. Antidepressant medications should not be used for treating AUD unless the patient has comorbid conditions, such as depression or anxiety disorder. Before starting pharmacotherapy for patients with AUD, the initial evaluation should include the assessment for comorbid psychiatric disorders. Benzodiazepines are not the primary treatment of AUD, except for alcohol detoxification or the treatment of alcohol withdrawal. Because of the risk for sedation, behavioral impairment, respiratory depression, benzodiazepines or other sedative-hypnotic agents should be limited.

To improve the quality of care and treatment outcomes for patients with AUD, APA developed this updated practice guideline to provide information on the comparative effectiveness of naltrexone, acamprosate, topiramate, gabapentin, and disulfiram. Additionally, the practice guideline includes recommendations and sugesstions related to the psychiatric evaluation of patients with AUD.


American Psychiatric Association (2018, January 19). The American Psychiatric Association Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder. Retrieved Feburary 19, 2018, from https://psychiatryonline.org/doi/pdf/10.1176/appi.books.9781615371969

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