What is the best treatment option for a patient with alcohol use disorder, peripheral neuropathy, kidney stones, hyperlipidemia, and chronic obstructive pulmonary disease (COPD), currently taking pregabalin, rosuvastatin, tiotropium, and albuterol?

Medication Selection for Alcohol Use Disorder in a Patient with Comorbidities

Acamprosate is the best treatment option for this patient with alcohol use disorder who desires to maintain abstinence, given their comorbid peripheral neuropathy, kidney stones, hyperlipidemia, and COPD.

Rationale for Acamprosate Selection

Acamprosate is the optimal choice for several reasons:

1. Efficacy for abstinence maintenance: Acamprosate has the strongest evidence for maintaining abstinence in detoxified patients, with a moderate confidence in evidence 1. It increases abstinence rates by 86% compared to placebo 1.

2. Renal safety profile: Unlike topiramate (which was prescribed but not filled) and naltrexone, acamprosate has no hepatic metabolism and is primarily excreted renally 2. This is important given the patient's history of kidney stones.

3. No hepatotoxicity risk: Acamprosate has no reported instances of hepatotoxicity 2, making it safer than naltrexone which carries hepatotoxicity concerns.

4. No interaction with current medications: Acamprosate does not have significant interactions with the patient's current regimen of pregabalin, rosuvastatin, tiotropium, and albuterol.

Comparison with Other Options

Topiramate

• While topiramate (75-400 mg/day) can be effective for AUD, it is not FDA-approved for this indication 2.
• Topiramate is primarily renally excreted, which is concerning given the patient's history of kidney stones.
• Topiramate may worsen cognitive function, which could be problematic if the patient has any alcohol-related cognitive impairment.

Naltrexone

• Naltrexone undergoes hepatic metabolism and carries hepatotoxicity concerns 2.
• While effective for reducing heavy drinking (RR = 0.81,95% CI, 0.73-0.90) 3, it may not be as effective as acamprosate for maintaining complete abstinence, which is this patient's goal.

Gabapentin

• While gabapentin shows promise for AUD treatment (RR = 1.66; 95% CI, 1.04-2.67 for abstinence) 3, the patient is already taking pregabalin, which has a similar mechanism of action.
• Adding gabapentin could increase the risk of side effects like sedation and dizziness.

Dosing and Administration

• Initial dosing: 666 mg three times daily 2
• Duration: Continue for at least 6-12 months if effective 1
• Monitoring: Regular assessment of medication compliance and alcohol consumption patterns

Comprehensive Treatment Approach

In addition to acamprosate:

1. Continue psychosocial support: The patient's participation in Alcoholics Anonymous is beneficial and should be encouraged.

2. Address cravings: Acamprosate specifically helps reduce cravings by modulating glutamate activity.

3. Continue thiamine and folic acid supplementation: The patient should complete the full 30-day course as prescribed at discharge.

4. Regular follow-up: Schedule frequent visits initially to monitor for medication side effects and treatment response.

Potential Challenges and Solutions

• Side effects: Diarrhea is the most common side effect of acamprosate (RD 0.11,95% CI 0.09 to 0.13) 4. Advise the patient about this possibility.

• Medication adherence: The three-times-daily dosing of acamprosate may present adherence challenges. Discuss strategies to improve adherence, such as medication reminders.

• Continued cravings: If cravings persist despite acamprosate, consider combination therapy with naltrexone if liver function is normal, as combination therapy may be more effective than monotherapy 1.

Acamprosate represents the safest and most effective option for this patient with alcohol use disorder and multiple comorbidities who desires to maintain abstinence.