What is the recommended use and dosage of Acamprosate (Campral) for treating alcohol dependence?

Acamprosate for Treating Alcohol Dependence

Acamprosate (Campral) is strongly recommended at a standard dose of 666 mg (two 333 mg tablets) taken three times daily for maintaining abstinence in alcohol-dependent patients who have already achieved abstinence at treatment initiation. 1

Indication and Efficacy

Acamprosate is specifically indicated for:

• Maintenance of abstinence from alcohol in patients with alcohol dependence
• Patients who are already abstinent at treatment initiation
• Use as part of a comprehensive management program that includes psychosocial support 1

The evidence strongly supports acamprosate's efficacy:

• It is the only intervention with moderate certainty evidence for increasing probability of abstinence (38% vs 25% with placebo) 2
• Acamprosate demonstrates reduced dropout rates (42% vs 50% with placebo) 2
• It is effective for maintaining abstinence for up to 12 months after detoxification 2, 3

Dosing Protocol

Standard Dosing

• Standard dose: 666 mg (two 333 mg tablets) three times daily 1
• Treatment should be initiated as soon as possible after alcohol withdrawal when abstinence is achieved 1
• Continue treatment even if patient relapses 1
• May be taken with or without food, though taking with meals was used in clinical trials 1

Renal Adjustment

• Moderate renal impairment (CrCl 30-50 mL/min): 333 mg three times daily 1
• Severe renal impairment (CrCl ≤30 mL/min): Contraindicated 1

Treatment Duration and Monitoring

• Treatment should be maintained for at least 6-12 months 3
• Regular monitoring of liver function and overall health is essential 3
• Continue treatment even if patient relapses during therapy 1

Contraindications

Acamprosate is contraindicated in:

• Patients with hypersensitivity to acamprosate or any components 1
• Patients with severe renal impairment (CrCl ≤30 mL/min) 1

Pharmacokinetics and Drug Interactions

• Peak plasma concentrations occur at 3-8 hours post-dose 1
• Terminal half-life ranges from 20-33 hours 1
• Primarily excreted unchanged in urine 1
• No significant drug interactions with alcohol, disulfiram, or diazepam 1
• When co-administered with naltrexone, acamprosate levels may increase by 25-33%, but no dosage adjustment is needed 1

Clinical Pearls and Pitfalls

Important Considerations

• Acamprosate does not help with acute alcohol withdrawal symptoms 1
• Efficacy has not been demonstrated in patients who have not undergone detoxification 1
• Efficacy has not been adequately assessed in polysubstance abusers 1
• Contains sodium sulfite, which may cause allergic reactions in susceptible individuals 1

Advantages over Other Medications

• No hepatotoxicity risk, making it suitable for patients with liver disease 3
• Can be used in patients who continue drinking alcohol (unlike disulfiram) 4
• Not metabolized by the liver, making it safe for patients with hepatitis or liver disease 4

Comprehensive Treatment Approach

For optimal outcomes, acamprosate should be used within a comprehensive treatment program:

• Complete alcohol abstinence should be the primary treatment goal 3
• Combine with psychosocial interventions such as cognitive behavioral therapy or support groups 3, 1
• Consider thiamine supplementation (100-300 mg/day) to prevent Wernicke encephalopathy 3

Acamprosate has demonstrated superior long-term outcomes compared to placebo, with studies showing 18.3% of acamprosate-treated patients remaining continuously abstinent at the end of treatment versus 7.1% with placebo 5.