What is the recommended dose and duration of naltrexone (Naltrexone) for the treatment of ethanol (ETOH) abuse?

Naltrexone Dosage and Duration for Alcohol Use Disorder

For alcohol use disorder treatment, naltrexone should be administered at 50 mg once daily for 3-12 months, with treatment discontinuation if a 5% reduction in body weight is not achieved after 12 weeks of therapy. 1, 2

Dosing Protocol

Initial Dosing

• Start with 25 mg for the first 1-3 days to assess tolerability 3
• Increase to standard maintenance dose of 50 mg once daily 1, 3

Alternative Dosing Regimens

• For supervised administration: 100 mg Monday/Wednesday and 150 mg Friday 2, 1
• Injectable extended-release formulation: 380 mg monthly (alternative to daily oral dosing) 2
• Higher doses (150 mg/day) have been studied in patients with prominent alcohol cravings with promising results, but are not standard practice 4

Duration of Treatment

• Standard duration: 3-6 months 3
• May extend up to 12 months in selected cases 3, 1
• Discontinue if patient has not achieved at least 5% reduction in drinking after 12 weeks on maintenance dose 3

Patient Selection and Preparation

• Ensure patient is opioid-free before starting treatment

  • Minimum 7-10 day opioid-free interval for short-acting opioids 1, 2
  • Consider naloxone challenge test if occult opioid dependence is suspected 1

• Best candidates for naltrexone therapy:

  • Motivated patients
  • Those with stable social support
  • Employed individuals
  • Married patients 2

Monitoring Protocol

• Baseline liver function tests before initiating therapy 2
• Follow-up liver function tests every 3-6 months 2
• Assess treatment response at 12 weeks; if no significant reduction in drinking (less than 5% reduction), consider discontinuation 3
• Monitor for side effects, particularly:
  • Nausea and vomiting (most common) 5, 6
  • Headache, dizziness, and arthralgia 6

Efficacy and Outcomes

• When combined with psychosocial interventions, naltrexone reduces relapse rates by approximately 50% compared to placebo 5, 7
• Approximately 27% of patients receiving naltrexone with cognitive coping skills therapy maintain complete abstinence from heavy drinking, compared to only 3% with placebo 8
• Naltrexone works by:
  • Decreasing alcohol craving 6
  • Blocking the pleasurable effects ("high") associated with alcohol consumption 5

Important Precautions

• Contraindicated in patients with:

  • Current opioid use or dependence
  • Acute hepatitis or liver failure
  • Need for opioid pain management 2

• Naltrexone is not hepatotoxic at the recommended 50 mg/day dosage for alcohol dependence 5, but caution is advised in patients with liver disease

  • In patients with moderate to severe hepatic impairment, total daily dose should not exceed 1 tablet daily 3

• Discontinue before procedures requiring opioid analgesia 3

Integration with Comprehensive Treatment

Naltrexone should be used as part of a comprehensive treatment approach that includes:

• Psychosocial interventions (cognitive behavioral therapy, motivational enhancement therapy)
• Community-based support groups
• Regular follow-up to ensure medication compliance 2, 6

Naltrexone is not aversive therapy and does not cause a disulfiram-like reaction with alcohol consumption 1. It is most effective when combined with behavioral interventions that enhance medication compliance 1, 7.