Is disulfiram (Antabuse) prescribed for alcohol use disorder?

Disulfiram Use in Alcohol Use Disorder

Disulfiram is not recommended for patients with alcoholic liver disease due to risk of hepatotoxicity. 1

Indications and Contraindications

• Disulfiram is FDA-approved as an aid in the management of selected chronic alcohol patients who want to remain in a state of enforced sobriety to facilitate supportive and psychotherapeutic treatment 2
• It is contraindicated in patients with alcoholic liver disease according to clinical practice guidelines 1
• Disulfiram should never be administered to a patient in a state of alcohol intoxication or without their full knowledge 2

Mechanism and Effects

• Disulfiram inhibits aldehyde dehydrogenase (ALDH), causing acetaldehyde buildup when alcohol is consumed 1
• This buildup results in unpleasant symptoms including flushing, dizziness, nausea, vomiting, arrhythmia, dyspnea, and headache 1
• It functions as an aversive therapy rather than directly addressing alcohol cravings 1, 3

Safety Concerns

• Disulfiram can cause hepatitis, which is sometimes fatal (estimated at 1 case in 30,000 patients treated/year) 4
• It undergoes hepatic metabolism and can cause liver damage 1
• Rare but serious adverse effects include psychosis, confusional states, peripheral neuropathy, and optic neuritis 4
• Common side effects include tiredness, headache, and sleepiness 4
• Drug interactions occur with medications that utilize the cytochrome P450 enzyme system 4

Alternative Medications for AUD with Liver Disease

• Baclofen is the preferred medication for patients with alcoholic liver disease 1, 5

  • It has demonstrated safety and efficacy in promoting alcohol abstinence in patients with liver cirrhosis 5
  • In a randomized trial of patients with alcoholic cirrhosis, a 12-week course of baclofen (10 mg three times daily) improved rates of total alcohol abstinence and decreased relapse compared to controls 1

• Acamprosate may be considered as it has no hepatic metabolism 1, 5

  • It reduces withdrawal effects and craving for alcohol 1, 5
  • Recommended dosage is 1,998 mg/day for patients ≥60 kg 1

Clinical Considerations

• Naltrexone is also not recommended for patients with alcoholic liver disease due to hepatotoxicity concerns 1, 5
• Pharmacotherapy should always be combined with psychosocial interventions for optimal outcomes 1, 5
• Alcohol abstinence is the most important treatment for alcoholic liver disease as it improves survival and prevents progression to cirrhosis 5

Efficacy Considerations

• Disulfiram is not a cure for alcoholism and when used alone, without proper motivation and supportive therapy, is unlikely to have substantive effects on drinking patterns 2
• It may reduce the frequency of alcohol consumption in compliant patients over the short term (e.g., 6 months) 3
• Prescription without accompanying education, counseling, and concomitant alcoholism therapy is not beneficial 3
• Disulfiram has no proven effect on the long-term outcome of alcoholism 3

In summary, while disulfiram is an FDA-approved medication for alcohol use disorder, it is not recommended for patients with alcoholic liver disease. Baclofen and acamprosate are safer alternatives for this population.