Medication Assisted Therapy
Most clinicians opt for Naltrexone as first line for alcohol use disorder (AUD) although Acamprosate may be slightly more effective at reducing urges. Naltrexone is a once daily medication, affordable, and has a relatively low side effect profile. Disulfram is typically considered as a last option given the significant adverse reaction if the patient uses with alcohol. In addition to these three options, topiramate and gabapentin seem to be an effective option for treating AUD, and are supported by evidence suggesting benefit; however, topiramate and gabapentin are not yet first line. Click on the title for a detailed, printable PDF.
Acamprosate / “Campral”
Dose: 666 mg PO TID
Primary Indication
Start ASAP after withdrawal when abstinence achieved; continue treatment even if relapse.
Adverse Reactions RARE, but include: Severe- suicidality, depression; Common- diarrhea, insomnia, anxiety, depression, asthenia, xerostomia
Retail Cost (without insurance): ~$230 for 180 tablets, GoodRx: ~ $67.50 for 180 tablets
Dosing: CrCl 30-50: 333 mg TID; CrCl <30: contraindicated. Child-Pugh Class A or B: no adjustment; Child-Pugh Class C: not defined
Naltrexone / “Revia”
Dose: 50mg PO QD
Primary Indication
Must be opioid free for 7-10 days to consider this option. Cautions: depression, suicidal ideation.
Adverse Reactions RARE, but include: Severe- suicidality, depression, hepatotoxicity; common- insomnia, nausea, vomiting, anxiety, headache, constipation
Retail Cost (without insurance): ~$35 for 30 tablets, GoodRx: ~$21.65 for 30 tablets
Dosing: caution with renal and hepatic impairment
Disulfiram / “Antabuse”
Dose: 125-500 mg PO QAM
Secondary Indication, if resistant to other medications
Start 500 mg PO qAM for 1-2 weeks, Maintenance 250 mg PO qAM
Patient must be abstinent from alcohol for >12 hours
Adverse Reactions RARE, but include: Severe - disulfiram-alcohol reaction (severe), psychosis, hepatotoxicity, peripheral neuropathy, optic neuritis. Common- rash, drowsiness, impotence, headache, metallic taste
Retail Cost (without insurance)- $175 for 30 tablets, GoodRx: ~ 25.55 for 30 tablets
Dosing: caution with renal and hepatic impairment
Topirimate/ “Topamax”
Dose 100-150 mg PO daily
Non FDA Approved, but new studies suggest efficacy
Start 25 mg PO in the morning and titrate weekly to effective dose, up to 75 mg daily.
Many study participants experience side effects, however, most are minor.
Adverse reactions include: Dizziness, somnolence, nervousness, numbness/paresthesia, psychomotor slowness, nausea.
Retail cost (without insurance) - $52 for 30 tablets, GoodRx ~$9.50 (lowest cost $3.00) for 30 tablets
Dosing: caution with hepatic impairment, but often, this will improve with cessation of alcohol.
Gabapentin/ “Neuraptine”
Dose 900-1800 mg PO daily
Non FDA Approved, but many studies suggest efficacy
Titrate up, starting at 300 mg daily for 5 days minimum per dose.
Common side effects include dizziness, somnolence, ataxia, and fatigue.
Retail cost (without insurance) - $9-20 per month for 90 capsules of 300 mg.
Dosing: get a creatnine at baseline. Monitor for suicidality
What’s the deal with SSRI use and initiation of the above medications?
There have been several studies that address the use of selective serotonin reuptake inhibitors (SSRIs) and treatment of unhealthy alcohol use. While SSRIs may improve concomitant depression, there is no evidence from recent meta-analyses that SSRIs, including citalopram, reduce drinking volume or drinking days.
If your patient is already on an SSRI, it IS safe to start an additional medication for reducing risky alcohol use. A 2008 study demonstrated that patients on both an SSRI and naltrexone had greater reduction of alcohol use and drinking days as compared to SSRI alone.
FAQ
My patient has Hep C and some depression. Can I still use these medications?
In what scenario should I not be prescribing MAT and refer to a psychiatrist?
Yes, as long as there is no significant hepatic damage/elevated LFT’s, it is ok to start medications (naltrexone, acamprosate). Check LFTs Q 1-2 months.
If you’re concerned about multiple co-morbidities, or significant suicidality, the patient may benefit from seeing a psychiatrist. If your intuition says, “This might not be safe,” it’s reasonable to refer!
Need more medication help?
The National Institute for Alcohol Abuse and Alcoholism has excellent resources, including a treatment navigator.
Check out this link from the National Institute on Drug Abuse to get full prescribing guide by RAND or click the link below to send for a warm handoff.