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CLINICIAN SUPPORT MATERIALS

Medications for Treating Alcohol Dependence

Naltrexone
(Depade®, ReVia®)
Extended-Release Injectable Naltrexone (Vivitrol®)
Acamprosate
(Campral®)
Disulfiram (Antabuse®)
Action
Blocks opioid receptors, resulting in reduced craving and reduced reward in response to drinking. Same as oral naltrexone; 30-day duration.Affects glutamate and GABA neurotransmitter systems, but its alcohol-related action is unclear.Inhibits intermediate metabolism of alcohol, causing a buildup of acetaldehyde and a reaction of flushing, sweating, nausea, and tachycardia if a patient drinks alcohol.
Contraindications
Currently using opioids or in acute opioid withdrawal; anticipated need for opioid analgesics; acute hepatitis or liver failure.Same as oral naltrexone, plus inadequate muscle mass for deep intramuscular injection; rash or infection at the injection site.Severe renal impairment (CrCl ≤ 30 mL/min).Concomitant use of alcohol or alcohol-containing preparations or metronidazole; coronary artery disease; severe myocardial disease; hypersensitivity to rubber (thiuram) derivatives.
Precautions
Other hepatic disease; renal impairment; history of suicide attempts or depression. If opioid analgesia is needed, larger doses may be required and respiratory depression may be deeper and more prolonged. Pregnancy Category C. Advise patients to carry a wallet card to alert medical personnel in the event of an emergency. For wallet card information, see www.niaaa.nih.gov/guide.Same as oral naltrexone, plus hemophilia or other bleeding problems.Moderate renal impairment (dose adjustment for CrCl between 30 and 50 mL/min); depression or suicidal ideation and behavior. Pregnancy Category C.Hepatic cirrhosis or insufficiency; cerebrovascular disease or cerebral damage; psychoses (current or history); diabetes mellitus; epilepsy; hypothyroidism; renal impairment. Pregnancy Category C. Advise patients to carry a wallet card to alert medical personnel in the event of an emergency. For wallet card information, see www.niaaa.nih.gov/guide.
Serious adverse reactions
Will precipitate severe withdrawal if the patient is dependent on opioids; hepatotoxicity (although does not appear to be a hepatotoxin at the recommended doses).Same as oral naltrexone, plus infection at the injection site; depression; and rare events including allergic pneumonia and suicidal ideation and behavior.Rare events include suicidal ideation and behavior.Disulfiram-alcohol reaction, hepatotoxicity, optic neuritis, peripheral neuropathy, psychotic reactions.
Common side effects
Nausea, vomiting, decreased appetite, headache, dizziness, fatigue, anxiety.Same as oral naltrexone, plus a reaction at the injection site; joint pain; muscle aches or cramps.Diarrhea, somnolence.Metallic after-taste, dermatitis, transient mild drowsiness.
Examples of drug interactions
Opioid medications (blocks action).Same as oral naltrexone.No clinically relevant interactions known.Anticoagulants such as warfarin; isoniazid; metronidazole; phenytoin; any nonprescription drug containing alcohol.
Usual adult dosage

Oral dose: 50 mg daily.

Before prescribing: Patients must be opioid-free for a minimum of 7 to 10 days before starting. If you feel that there’s a risk of precipitating an opioid withdrawal reaction, administer a naloxone challenge test. Evaluate liver function.

Laboratory Followup: Monitor liver function.

IM dose: 380 mg given as a deep intramuscular gluteal injection, once monthly.

Before prescribing: Same as oral naltrexone, plus examine the injection site for adequate muscle mass and skin condition.

Laboratory Followup: Monitor liver function.

Oral dose: 666 mg (two 333-mg tablets) three times daily; or for patients with moderate renal impairment (CrCl 30 to 50 mL/min), reduce to 333 mg (one tablet) three times daily.

Before prescribing: Evaluate renal function. Establish abstinence.

Oral dose: 250 mg daily (range 125 mg to 500 mg).

Before prescribing: Evaluate liver function. Warn the patient (1) not to take disulfiram for at least 12 hours after drinking and that a disulfiram-alcohol reaction can occur up to 2 weeks after the last dose and (2) to avoid alcohol in the diet (e.g., sauces and vinegars), over-the-counter medications (e.g., cough syrups), and toiletries (e.g., cologne, mouthwash).

Laboratory Followup: Monitor liver function.

Note: This chart highlights some of the properties of each medication. It does not provide complete information and is not meant to be a substitute for the package inserts or other drug reference sources used by clinicians. For patient information about these and other drugs, the National Library of Medicine provides MedlinePlus. Whether or not a medication should be prescribed and in what amount is a matter between individuals and their health care providers. The prescribing information provided here is not a substitute for a provider's judgment in an individual circumstance, and the NIH accepts no liability or responsibility for use of the information with regard to particular patients.

The information in this chart was drawn primarily from package inserts and references 18, 20, 22, and 26 (see pages 33-34).
January 2007

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