What medications are used to treat alcoholism?

Medications for Treating Alcoholism

Baclofen is the preferred medication for treating alcoholism, especially in patients with alcoholic liver disease, as it has demonstrated safety and efficacy in promoting alcohol abstinence in patients with liver cirrhosis. 1, 2

FDA-Approved Medications

• Naltrexone (oral 50mg daily or injectable 380mg monthly) - Reduces relapse rates, cravings, and increases abstinence rates by blocking opioid receptors, but is not recommended for patients with alcoholic liver disease due to hepatotoxicity concerns 1, 3
• Acamprosate (666mg three times daily) - Reduces relapse rates and increases abstinence rates by modulating the glutamatergic receptor system, with no reported instances of hepatotoxicity 1, 2
• Disulfiram - Although effective, should be avoided in patients with severe alcoholic liver disease due to possible hepatotoxicity 1, 2

Preferred Medication for Patients with Liver Disease

• Baclofen (30-60mg daily) is the only alcohol pharmacotherapy tested in alcoholics with significant liver disease, demonstrating safety and efficacy in promoting alcohol abstinence in alcoholic cirrhotic patients 1, 2
• In a randomized trial with both compensated and decompensated cirrhotic patients, a 12-week course of baclofen (10mg three times daily) improved rates of total alcohol abstinence and decreased relapse during 1 year of observation with an acceptable safety profile 1
• Caution: Baclofen may impair mentation, a side effect that may be exacerbated in advanced liver disease; patients with hepatic encephalopathy were excluded from trials 1

Promising Alternative Medications

• Topiramate (75-400mg daily) has demonstrated safety and efficacy in reducing heavy drinking and may decrease liver enzyme levels, but has not been specifically tested in patients with alcoholic liver disease 1, 2
• Gabapentin (600-1,800mg daily) can be considered for patients with renal function monitoring 1, 4
• Ondansetron has shown efficacy but appears limited to "early onset" alcoholics 1

Medication Safety Considerations

• Naltrexone should not be used in patients with alcoholic liver disease due to hepatotoxicity concerns 1, 2
• Disulfiram should be avoided in patients with severe alcoholic liver disease due to hepatotoxicity risk 1, 2
• Acamprosate has no hepatic metabolism and is likely safe in liver disease, though it has not been specifically tested in cirrhotic patients 1

Acute Alcohol Withdrawal Management

• Benzodiazepines are the gold standard for treating alcohol withdrawal syndrome 2, 5
• Short and intermediate-acting benzodiazepines (e.g., lorazepam, oxazepam) are safer in patients with hepatic dysfunction compared to long-acting ones (e.g., diazepam, chlordiazepoxide) 1, 2
• Essential nutritional supplementation with thiamine (100-300mg/day for 4-12 weeks) is crucial to prevent Wernicke encephalopathy 2, 5

Clinical Approach Algorithm

1. Assess liver function: If patient has alcoholic liver disease, choose baclofen as first-line therapy 1, 2
2. If no liver disease: Consider naltrexone (oral or injectable) as first-line therapy 3, 6
3. If naltrexone is contraindicated: Use acamprosate as an alternative 1, 6
4. For patients with poor medication adherence: Consider injectable naltrexone (380mg monthly) if no liver disease 3
5. For patients with anxiety or insomnia: Consider gabapentin or topiramate as adjunctive therapy 1, 4

Common Pitfalls and Caveats

• Naltrexone requires patients to be opioid-free for 7-10 days before initiation to avoid precipitated withdrawal 3
• Medication alone is insufficient; psychosocial interventions and support groups significantly improve outcomes 1, 3
• Baclofen should be used cautiously in patients with hepatic encephalopathy due to potential mental status effects 1
• Regular liver function monitoring is essential when using medications metabolized by the liver 2