Medications for AUD include naltrexone, acamprosate, disulfiram, and gabapentin. Several other medications have been used off-label but are unlikely to be prescribed in the ED.

Naltrexone

• Dosing: 50 mg PO daily OR 380 mg IM every four weeks
• Contraindicated in patients with concurrent opioid use, as it may lead to precipitated withdrawal or ineffectiveness.¹³
• Naloxone challenge: a trial dose of 0.4 mg IV should be given, and the patient observed for signs of withdrawal. There are no data regarding a consensus dose, and dosing has ranged from 0.2 mg to 0.6 mg.^13,14
• There is no longer a black-box warning for its use in patients with liver dysfunction, and research has shown that it is safe for use in these patients. But some physicians may feel more comfortable ordering baseline LFTs, although this is not necessary.¹⁵
• Evidence:
  • Naltrexone was found to have a number needed to treat (NNT) of 11 to reduce the risk of one patient returning to heavy drinking.¹⁶
  • An emergency department pilot study demonstrated that initiation of 50 mg was feasible and effective, with 33 percent staying engaged in treatment at one month.¹¹
  • Patients favored the IM extended-release naltrexone, which was linked to a notable enhancement in quality of life and a decrease in alcohol intake.^11,17,18

Acamprosate

• Dosing: 666 mg (two 333 mg tablets) PO TID
• Safe for use in patients with opioid use disorder and liver disease.
• May require up to six pills daily.
• Evidence:
  • Found to have an NNT of 11 to prevent one patient from returning to heavy drinking.^16,19
  • Most effective when patients have already stopped drinking, and has been found to significantly increase the likelihood of maintaining abstinence.¹⁶
  • Has been shown to be significantly more effective than baclofen for reducing alcohol use.²⁰

Gabapentin

• Dosing: 300-600 mg PO TID
• It is currently FDA-approved as an antiepileptic and for neuropathic pain, but is not currently approved for use in AUD.²¹
• There are reports of abuse and a potential risk of diversion, but the data are inconclusive.^12,22
• Evidence:
  • One randomized, controlled trial (RCT) of 150 patients demonstrated that gabapentin significantly increased the rates of abstinence, reduced cravings, and heavy drinking days when compared to placebo.²³
  • Studies have found that it has a lower NNT than acamprosate or naltrexone, at 8, but there has not been any sustained efficacy demonstrated in long-term studies.²³

Disulfiram

• Dosing: 250 mg PO daily
• An aversive agent that can induce the “disulfiram reaction:”
  

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