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Pharmacotheraphy for Relapse Prevention

for Health Care Providers

Table 1. Pharmacotherapy for Relapse Prevention

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MedicationStandard DosageComments
Naltrexone (oral)50-100 mg QD for ≥3 months
  • Start upon cessation of alcohol use
  • Optimal duration of therapy not known; most study subjects treated for 3-4 months; treatment effects tend to wane after therapy is stopped
  • Pure opioid receptor antagonist
  • Avoid in patients who use opioids (precipitates withdrawal symptoms)
  • Avoid in patients with liver failure
  • Possible adverse effects: nausea, vomiting, headache, insomnia, hepatotoxicity
  • Check LFTs before and after treatment
Naltrexone (IM)190 mg IM monthly for ≥3 months
  • Start upon or just after cessation of alcohol use; greater benefit may be seen in patients who achieve some duration of alcohol abstinence (eg, 2-4 days) before the initial injection of naltrexone
  • Useful for patients with adherence issues
  • See PBM Criteria for Use
  • Pure opioid receptor antagonist
  • Possible adverse effects: nausea, vomiting, headache, hepatotoxicity, injection site reactions
  • Avoid in patients who use opioids (precipitates withdrawal symptoms)
  • Avoid in patients with liver failure
  • 380 mg dose has been standard but does not confer more abstinence advantage and causes more side effects
Disulfiram (Antabuse)250 mg QD as adjunct during outpatient treatment period
  • Start ≥12 hours after last alcohol consumption
  • Disulfiram acts as an acetaldehyde dehydrogenase inhibitor
  • Concurrent alcohol consumption increases plasma acetaldehyde concentrations 5-10 times, causing flushing, tachycardia, hypotension, nausea, vomiting, vertigo, and anxiety within 15 minutes
  • Other possible adverse effects include delirium, hepatotoxicity (monitor LFTs before treatment and every 3 months during treatment), neuropathy
  • Do not administer to patients who take ARV syrups or other medications that contain alcohol or propylene glycol (eg, RTV, LPV/r, and FPV liquid formulations)
  • Patients must avoid OTC medications containing alcohol (eg, cough syrup), as well as sauces, vinegars, and foods containing alcohol
  • Multiple other drug interactions, including with phenytoin, rifampin, isoniazid, and warfarin
Acamprosate666 mg TID for 3 months
  • See PBM Criteria for Use
  • Should only be used in patients with at least 4 days of abstinence and only mild withdrawal symptoms who are in a comprehensive management program including appropriate behavioral interventions
  • Start as soon as possible after abstinence is established and continue through relapses
  • Adjust dosage for renal failure:
    • CrCl 30-50: 333 mg TID
    • CrCl <30: contraindicated
  • GABA analogue; decreases excitatory glutamergic neurotransmission during withdrawal
  • Patients should be closely monitored for depression or suicidal thinking
  • Other possible adverse effects: diarrhea, somnolence
  • COMBINE study did not show that acamprosate was more effective than placebo

From Alcohol Misuse
Primary Care of Veterans with HIV
Office of Clinical Public Health Programs
Veterans Health Administration, 2009