A 55-year old woman with a history of atrial fibrillation, cirrhosis from Hepatitis C, and at-risk alcohol use presents to the clinic for follow up. She takes her metoprolol and apixaban regularly. She has noticed occasional fatigue and nausea in the morning.
You ask her about alcohol use. She says that with recent work stress and the COVID pandemic, she is drinking a bottle of wine a night and has missed work a few times because she felt too hungover. When she wakes up, she looks forward to happy hour.
When you ask her if she is concerned about her alcohol use, she says she could probably decrease the amount but her goal is not to stop drinking altogether. She lives in California and enjoys wine.
You diagnose her with alcohol use disorder (AUD) and introduce the diagnosis to her. You express concern about her current level of drinking and offer treatment. Her last AST/ALT are 58/42 with INR and sCr in the normal range. She declines counseling at this time and you wonder what FDA-approved pharmacotherapy you could recommend for a patient with moderate AUD who wants to reduce use but may not be ready to quit?
Answer: A! There are currently three FDA-approved medications for moderate-to-severe AUD: naltrexone, acamprosate, and disulfiram. Gabapentin does not have an FDA approved indication for moderate AUD.
Naltrexone has a number needed to treat (NNT) of 12* to prevent return to heavy drinking and is usually the first line medication option. It can be taken as a daily pill or a monthly IM injection. It can be given to reduce cravings or hazardous or heavy drinking in patients who are still continuing to drink. It can safely be given to patients with cirrhosis who are not acutely decompensated, have LFTs <200, and are Child-Pugh class A or B. The typical starting dose of naltrexone is 25mg oral daily (take in the AM as some have insomnia with it) for 3 days to ensure tolerability prior to going to 50mg daily. Some people will stay at naltrexone 25mg daily because of nausea or GI upset at higher doses. People can stay on naltrexone for as long as they are meeting their goal to reduce use.
Naltrexone would not be an option for someone on chronic opioid therapy who wanted to reduce their alcohol use but not quit (because it is an opioid antagonist). For patients on chronic opioids, I would recommend discussing medications based on their goals such as non-FDA approved medications like gabapentin and topiramate.
Acamprosate is given as 2 pills, 3 times a day and has been studied to promote abstinence in patients whose goal is to stop drinking entirely.
Disulfiram is a pharmacologic punishment that causes adverse effects if someone drinks. It is used rarely, and only prescribed to patients with a goal of complete abstinence.
Kranzler HR, Soyka M. Diagnosis and Pharmacotherapy of Alcohol Use Disorder: A Review. JAMA. 2018;320(8):815–824. doi:10.1001/jama.2018.11406
Jonas DE, Amick HR, Feltner C et al. Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis. JAMA. 2014 May 14; 311(18):1889-900. doi:10.1001/jama.2014.3628.Send a Comment