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

Acamprosate for Alcohol Dependence

Acamprosate is the only medication with sufficient high-quality evidence to be recommended for maintaining abstinence in detoxified alcohol-dependent patients, dosed at 666 mg (two 333 mg tablets) three times daily. 1, 2, 3

Indication and Patient Selection

• Acamprosate must only be initiated after the patient has completed detoxification and achieved abstinence—it has no demonstrated efficacy in patients who are still drinking. 1, 3

• The medication is specifically indicated for maintenance of abstinence, not for inducing initial abstinence or managing acute withdrawal. 1, 2

• Acamprosate is more effective at maintaining rather than inducing remission, making it appropriate only for patients who have already stopped drinking. 1, 2

Dosing Regimen

Standard dosing: 3

• 666 mg (two 333 mg tablets) three times daily for patients with normal renal function
• Total daily dose: 1998 mg/day for patients ≥60 kg body weight
• For patients <60 kg: reduce dose by one-third to 1332 mg/day (one tablet three times daily) 1

Renal impairment adjustments: 3

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

Timing considerations: 1, 3

• Initiate 3-7 days after last alcohol consumption, once withdrawal symptoms have resolved
• Treatment should be started as soon as possible after the withdrawal period
• Dosing may be done without regard to meals, though taking with meals is suggested for patients who eat three regular meals daily

Treatment Duration

• Standard treatment period: 3-6 months, though treatment can extend up to 12 months. 1

• Therapeutic concentration is reached within 1-2 weeks of initiating treatment. 1

• Continue acamprosate even if the patient relapses—do not discontinue medication during relapse episodes. 3

Efficacy Evidence

Acamprosate demonstrates superior outcomes compared to placebo with moderate certainty evidence: 1, 2

• Increases absolute probability of abstinence from 25% to 38%
• Reduces dropout rates from 50% to 42%
• Improves treatment completion rates, time to first drink, and cumulative abstinence duration 4, 5

Comparative effectiveness: 1

• Acamprosate is the only intervention with moderate-quality evidence for both effectiveness and acceptability up to 12 months
• Evidence for naltrexone and disulfiram is insufficient to conclude they improve abstinence in detoxified patients
• Combination therapy with acamprosate plus naltrexone shows low-quality evidence and is not routinely recommended

Unique Advantages in Liver Disease

Acamprosate is the preferred medication for patients with alcoholic liver disease: 6

• Not metabolized by the liver—safe in hepatic impairment
• Not impacted by ongoing alcohol use
• Can be administered to patients with hepatitis or liver disease (a common comorbidity)
• No hepatotoxicity risk, unlike naltrexone which is contraindicated in liver disease 1

Safety Profile

Acamprosate has an excellent tolerability profile: 3, 6, 5

• Most common side effect: occasional diarrhea
• No serious drug-related adverse events in clinical trials
• Low propensity for drug interactions
• Contraindication: Contains sodium sulfite—may cause allergic reactions in sulfite-sensitive individuals, particularly asthmatics

Essential Psychosocial Component

Acamprosate must be combined with comprehensive psychosocial support—medication alone is insufficient. 1, 3

Required components include: 1

• Individual counseling or cognitive behavioral therapy
• Group therapy (e.g., Alcoholics Anonymous)
• Family therapy and social support
• Psychoeducation about alcohol dependence

Clinical Algorithm

1. Confirm patient has completed detoxification and achieved abstinence (if still drinking, acamprosate will not work) 1, 3

2. Assess renal function (adjust dose for CrCl 30-50 mL/min; contraindicated if CrCl ≤30 mL/min) 3

3. Initiate acamprosate 666 mg three times daily within 3-7 days after last drink, once withdrawal symptoms resolve 1, 3

4. Establish concurrent psychosocial treatment program before or simultaneously with medication 3

5. Continue treatment for 3-6 months minimum, extending up to 12 months based on response 1

6. Maintain medication even during relapse episodes—do not discontinue 3

Common Pitfalls to Avoid

• Do not prescribe acamprosate to patients who have not yet achieved abstinence—it will be ineffective. 1, 3

• Do not use acamprosate as monotherapy—always combine with psychosocial interventions. 3

• Do not discontinue medication if patient relapses—continue treatment to support return to abstinence. 3

• Do not use in severe renal impairment (CrCl ≤30 mL/min)—this is an absolute contraindication. 3

• Do not assume "cutting back" is sufficient—complete abstinence must be the goal, as there is significant recidivism risk with partial reduction. 1