How should acamprosate be initiated in a patient with alcohol use disorder?

From the Guidelines

Acamprosate should be initiated 3-7 days following the last episode of alcohol consumption, after withdrawal symptoms have resolved, with a standard dosage of 1998 mg/day for patients with a body weight of ≥60 kg. The treatment should be started as soon as possible after the completion of alcohol withdrawal and continue even if the patient relapses, as part of a comprehensive treatment program that includes counseling and support 1. Key considerations for initiating acamprosate include:

• The desired concentration for acamprosate is reached within 1-2 weeks of initiating treatment, and it is effective at maintaining abstinence in alcohol-dependent patients following withdrawal 1.
• For patients with a body weight of <60 kg, the dosage should be decreased by one-third, to ensure safe and effective treatment 1.
• Acamprosate helps reduce cravings and maintain abstinence by normalizing brain glutamate activity that becomes dysregulated during chronic alcohol use, with minimal drug interactions, making it suitable for patients with liver disease 1.
• Common side effects include diarrhea, nausea, and abdominal discomfort, which typically improve with continued use, and treatment duration is typically at least 3-6 months, but may be continued longer if beneficial 1. According to the most recent and highest quality study, acamprosate was found to be the only intervention with enough high-quality evidence to conclude that it is better at maintaining alcohol abstinence than placebo 1.

From the FDA Drug Label

Treatment with acamprosate calcium delayed-release tablets should be initiated as soon as possible after the period of alcohol withdrawal, when the patient has achieved abstinence, and should be maintained if the patient relapses. The recommended dose of acamprosate calcium delayed-release tablets is two 333 mg tablets (each dose should total 666 mg) taken three times daily.

Initiation of Acamprosate: Acamprosate should be started as soon as possible after the period of alcohol withdrawal, when the patient has achieved abstinence.

• The recommended dose is 666 mg (two 333 mg tablets) taken three times daily.
• A lower dose may be effective in some patients.
• Dosing with meals is suggested in patients who regularly eat three meals daily.
• Treatment with acamprosate should be part of a comprehensive psychosocial treatment program 2.
• For patients with moderate renal impairment (creatinine clearance of 30-50 mL/min), a starting dose of one 333 mg tablet taken three times daily is recommended 2.

From the Research

Initiation of Acamprosate in Alcohol Use Disorder

• Acamprosate is initiated as an adjunct to psychosocial interventions to facilitate the maintenance of abstinence in alcohol-dependent patients 3.
• The medication has been shown to be generally well tolerated, with a low propensity for drug interactions, and may be used without dosage adjustment in patients with mild to moderate hepatic impairment 3.
• However, dosage adjustments or contraindications are recommended in patients with renal impairment 3.

Dosage and Administration

• The typical dosage of acamprosate is 666 mg three times daily 4.
• The medication can be administered to patients with hepatitis or liver disease, as it is not metabolized by the liver and is not impacted by alcohol use 5.

Efficacy and Safety

• Acamprosate has demonstrated efficacy in reducing the risk of returning to any drinking and increasing the cumulative duration of abstinence in individuals with alcohol dependence 5.
• The medication has been shown to be safe and feasible in patients with liver transplant for alcohol-associated liver disease, with no reported grade 4/5 adverse events 4.
• Acamprosate is one of the four medications approved by the FDA for the treatment of alcohol use disorder, along with disulfiram, oral naltrexone, and naltrexone IM 6.