What is the role of Antabuse (disulfiram) in the treatment of Alcohol Use Disorder (AUD)?

From the Guidelines

Antabuse (disulfiram) is not recommended as a first-line treatment for Alcohol Use Disorder (AUD) due to its potential hepatotoxicity and limited evidence of efficacy in maintaining abstinence, as noted in the 2020 study published in the BMJ 1. The typical dosage of Antabuse is 250-500 mg taken once daily, with treatment often continuing for months to years depending on individual needs and response. Antabuse works by blocking the enzyme aldehyde dehydrogenase, which causes a buildup of acetaldehyde when alcohol is consumed, leading to an unpleasant reaction including flushing, nausea, vomiting, headache, chest pain, and palpitations within 10-30 minutes of alcohol consumption, lasting for 30 minutes to several hours. Patients must understand that this reaction will occur with any alcohol consumption, including in foods, medications, and topical products. Before starting Antabuse, patients should be alcohol-free for at least 12 hours, and they should be informed that the medication's effects can persist for up to 14 days after the last dose. Antabuse is most effective when combined with counseling or behavioral therapy and requires strong motivation and compliance. It is contraindicated in patients with certain cardiac conditions, psychosis, or severe liver disease, and should be used cautiously in those taking other medications that might interact with it, as stated in the 2013 study published in Clinical and Molecular Hepatology 1. Other medications such as acamprosate, naltrexone, and baclofen may be considered as alternative treatments for AUD, as suggested in the 2020 study published in Hepatology 1 and the 2012 study published in the Journal of Hepatology 1. The 2022 study published in Liver International 1 also recommends considering pharmacological treatment for promoting the maintenance of alcohol consumption targets in dependent patients. However, the choice of medication should be based on individual patient needs and medical history, and patients should be closely monitored for potential side effects and interactions. In terms of specific patient populations, the 2010 study published in Hepatology 1 notes that disulfiram should be avoided in patients with severe ALD due to possible hepatotoxicity. Overall, while Antabuse may be effective in some cases, its use should be carefully considered and monitored due to its potential risks and limitations. Key points to consider when prescribing Antabuse include:

• Potential hepatotoxicity and limited evidence of efficacy
• Importance of combining with counseling or behavioral therapy
• Need for strong motivation and compliance
• Contraindications in certain cardiac conditions, psychosis, or severe liver disease
• Potential interactions with other medications
• Alternative treatment options such as acamprosate, naltrexone, and baclofen.

From the FDA Drug Label

Disulfiram is an aid in the management of selected chronic alcohol patients who want to remain in a state of enforced sobriety so that supportive and psychotherapeutic treatment may be applied to best advantage. Disulfiram produces a sensitivity to alcohol which results in a highly unpleasant reaction when the patient under treatment ingests even small amounts of alcohol.

The role of Antabuse (disulfiram) in the treatment of Alcohol Use Disorder (AUD) is to aid in the management of selected chronic alcohol patients by producing a sensitivity to alcohol, resulting in an unpleasant reaction when alcohol is ingested. This reaction is intended to discourage alcohol consumption and support sobriety.

• Key points:
  • Disulfiram is not a cure for alcoholism
  • It is unlikely to have a substantive effect on drinking patterns without proper motivation and supportive therapy
  • The disulfiram-alcohol reaction can persist as long as alcohol is being metabolized 2 2

From the Research

Overview of Antabuse for AUD

• Antabuse, also known as disulfiram, is a medication used in the treatment of Alcohol Use Disorder (AUD) 3, 4.
• It works by producing an aversive reaction when ethanol is consumed, typically at a dose between 250 mg/day and 500 mg/day 4.
• Disulfiram is recommended as a second-line treatment option by several national treatment guidelines due to safety concerns and lack of high-quality comparative studies 3.

Efficacy of Antabuse

• Disulfiram can be a useful treatment for a highly selected group of patients with no medical or psychiatric contraindications, high motivation for abstinence, and adequate family support 3.
• It is probably effective in reducing the frequency of alcohol consumption in the compliant patient over the short term (e.g., 6 months) 4.
• Certain subgroups of patients, such as those who are older, those who are more socially stable, and those who are well-motivated, may experience a beneficial effect for longer periods 4.

Safety and Tolerability

• Disulfiram can cause cardiac, hepatic, and neurologic toxicity, and patients must be clearly informed of the risks of drinking while taking the drug 4.
• The safety profile of disulfiram needs to be balanced with the treatment objective, individual patient preferences, and comorbid conditions 5.
• Appropriate treatment will be based on the unique risk-benefit profile in each case 5.

Comparison with Other Treatments

• Naltrexone combined with disulfiram or acamprosate has been associated with a significantly lower risk of AUD-hospitalization compared with no use of AUD medication 6.
• Disulfiram is one of several medications available for the treatment of AUD, including acamprosate, naltrexone, and nalmefene 7, 6, 5.
• The choice of medication should be based on individual patient needs and circumstances 7, 6, 5.