What are the starting and maintenance doses of Antabuse (disulfiram) for a patient with alcohol use disorder?

Disulfiram (Antabuse) Dosing for Alcohol Use Disorder

The FDA-approved starting dose of disulfiram is 500 mg daily for 1-2 weeks, followed by a maintenance dose of 250 mg daily (range 125-500 mg), with treatment continuing for months to years until permanent self-control is established. 1

Starting Dose Protocol

• Begin with 500 mg once daily for the first 1-2 weeks after the patient has abstained from alcohol for at least 12 hours 1
• The medication is typically taken in the morning, though it may be taken at bedtime if sedation occurs 1
• If sedation is problematic, the dosage may be adjusted downward during the initial phase 1

Maintenance Dosing

• The standard maintenance dose is 250 mg daily, with an acceptable range of 125-500 mg depending on tolerance and response 1
• The maximum daily dose should not exceed 500 mg 1
• Daily, uninterrupted administration must continue until the patient is fully recovered socially and a basis for permanent self-control is established 1

Duration of Treatment

• Maintenance therapy may be required for months or even years, depending on the individual patient 1
• Disulfiram is most effective when used for at least 6-12 months in supervised treatment programs 2, 3
• The drug should be considered only one component of a comprehensive treatment program that includes counseling, education, and ongoing support 2

Critical Contraindications and Cautions

Disulfiram is contraindicated in patients with hepatic insufficiency according to its FDA labeling, though French guidelines note this absolute contraindication is not supported by solid data and should be assessed case-by-case 4

Additional contraindications include: 5

• Major psychosis or drug addiction
• Cardiovascular disease (particularly in patients over 50 years)
• Pregnancy
• Diabetes mellitus, epilepsy, asthma (use with caution)

Clinical Context and Effectiveness

• Disulfiram works as an aversive therapy by inhibiting aldehyde dehydrogenase, causing accumulation of acetaldehyde when alcohol is consumed, resulting in flushing, nausea, vomiting, arrhythmia, dyspnea, and headache 4
• The drug is probably effective in reducing frequency of alcohol consumption in compliant patients over 6 months, particularly in older, socially stable, well-motivated patients 2
• Disulfiram has no proven effect on long-term outcome of alcoholism and is not commonly used in current practice 4
• Supervised compliance significantly improves effectiveness, especially in work-related alcohol problems 3

Common Pitfalls to Avoid

• Never administer disulfiram until the patient has abstained from alcohol for at least 12 hours 1
• Do not prescribe without accompanying education, counseling, and concomitant alcoholism therapy, as this approach is not beneficial 2
• If patients report drinking without symptoms while on adequate doses, assume they are not actually taking the medication until directly observed administration is confirmed 1
• Avoid test alcohol reactions in patients over 50 years of age due to cardiovascular risks 1
• Monitor for cardiac, hepatic, and neurologic toxicity even within the standard dosage range 2

Monitoring Requirements

• The patient must clearly understand the risks of drinking while taking disulfiram 2
• Continued clinical supervision and monitoring for efficacy and side effects is mandatory 2
• At the usual dosage of 250 mg/day, disulfiram does not significantly increase psychiatric complications or drug interactions, making it suitable for patients with comorbid psychiatric disorders 6