What is the recommended approach for a patient with Alcohol Use Disorder (AUD) who has shown no significant improvement in reducing drinking while on Acamprosate (Campral)?

From the Guidelines

For a patient with alcohol use disorder who has not responded to acamprosate, the recommended approach is to switch to an alternative FDA-approved medication such as naltrexone. Naltrexone (50mg daily orally or 380mg monthly injectable) is often the next choice as it works through a different mechanism by blocking opioid receptors, reducing alcohol's pleasurable effects and cravings 1. When switching medications, it's essential to discontinue acamprosate and allow a brief washout period of 3-5 days before starting the new medication. Combining the medication change with evidence-based psychosocial interventions such as cognitive-behavioral therapy or motivational enhancement therapy is crucial for improved outcomes. The lack of response to acamprosate is not uncommon, as medication effectiveness varies between individuals based on genetic factors, drinking patterns, and severity of dependence. Regular follow-up appointments every 2-4 weeks initially are vital to monitor response to the new treatment approach and adjust as needed. Some key points to consider when making this decision include:

• The patient's motivation and willingness to try a new medication
• The potential side effects and interactions of the new medication
• The importance of combining medication with psychosocial interventions for optimal outcomes
• The need for regular follow-up and monitoring to adjust the treatment plan as needed. According to a recent study published in the BMJ in 2020, naltrexone has been shown to be effective in maintaining abstinence from alcohol, with a corresponding absolute probability of abstinence of 31% 1. Additionally, the French Association for the Study of the Liver and the French Alcohol Society clinical guidelines recommend considering pharmacological treatment, including naltrexone, for promoting the maintenance of alcohol consumption targets in dependent patients 1. Overall, switching to naltrexone is a reasonable next step for a patient who has not responded to acamprosate, and combining this with psychosocial interventions and regular follow-up can help improve outcomes.

From the FDA Drug Label

Treatment with acamprosate calcium delayed-release tablets should be part of a comprehensive management program that includes psychosocial support The efficacy of acamprosate calcium delayed-release tablets in promoting abstinence has not been demonstrated in subjects who have not undergone detoxification and not achieved alcohol abstinence prior to beginning acamprosate calcium delayed-release tablets treatment Acamprosate calcium delayed-release tablets should be used as part of a comprehensive psychosocial treatment program.

The patient has been on acamprosate but reports no significant improvement in reducing drinking. The recommended approach is to continue or adjust the comprehensive management program that includes psychosocial support, as the efficacy of acamprosate has not been demonstrated in subjects who have not achieved alcohol abstinence prior to beginning treatment 2.

• Assess the patient's adherence to the treatment program
• Evaluate the need for adjustment of the psychosocial support
• Consider alternative treatment options

From the Research

Treatment Approach for Alcohol Use Disorder

The patient has been taking acamprosate but reports no significant improvement in reducing drinking. The recommended approach in this case is to consider alternative medications or combination therapy.

• Alternative medications:
  • Naltrexone: Studies have shown that naltrexone can be effective in reducing alcohol consumption and cravings 3, 4, 5.
  • Disulfiram: Disulfiram has been shown to be effective in reducing alcohol-related hospitalizations when used as monotherapy or in combination with naltrexone or acamprosate 3.
• Combination therapy:
  • Combining acamprosate with other medications such as naltrexone or disulfiram may be considered, although the evidence for this approach is limited 6, 3.
  • Cognitive behavioral therapy (CBT) can be used in combination with medication to improve treatment outcomes 4.

Considerations for Treatment

When selecting a treatment approach, consider the following factors:

• Patient's medical history and comorbidities
• Patient's previous response to treatment
• Potential side effects and interactions with other medications
• Patient's preferences and motivations for treatment

Monitoring and Follow-up

Regular monitoring and follow-up are essential to assess the patient's response to treatment and make adjustments as needed. This may include:

• Regular check-ins with the patient to assess their drinking habits and cravings
• Monitoring for potential side effects and interactions with other medications
• Adjusting the treatment plan as needed to optimize outcomes.