What are the potential side effects of Disulfiram (Antabuse) in patients with a history of liver disease or other comorbidities?

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Last updated: January 28, 2026 • View editorial policy

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Disulfiram Side Effects

Disulfiram carries significant risks of hepatotoxicity including potentially fatal hepatic failure, and is absolutely contraindicated in patients with alcoholic liver disease. 1, 2

Critical Hepatotoxicity Risk

  • Severe and sometimes fatal hepatitis can develop even after many months of therapy, occurring in patients with or without prior history of abnormal liver function. 3
  • The estimated frequency of disulfiram-induced fatal hepatitis is approximately 1 case per 30,000 patients treated per year. 4
  • Most hepatotoxic reactions develop between 2 weeks to 2 months after starting treatment, though they can occur later; among reported cases, 6 patients died from disulfiram-associated hepatotoxicity. 5
  • Hepatic toxicity has resulted in liver transplantation or death, making this the most serious adverse effect. 3

Absolute Contraindications

  • Disulfiram is contraindicated in patients with alcoholic liver disease according to the American Association for the Study of Liver Diseases. 1, 2
  • The drug should be used with extreme caution (or avoided) in patients with hepatic cirrhosis or insufficiency. 3
  • For patients with alcohol-associated liver disease requiring pharmacotherapy, baclofen is the preferred medication for maintaining abstinence in those with cirrhosis, while acamprosate is the preferred agent for those with adequate renal function due to its complete lack of hepatotoxicity. 1, 2

Disulfiram-Alcohol Reaction

  • When combined with even small amounts of alcohol, disulfiram causes toxic acetaldehyde accumulation producing flushing, throbbing headache, nausea, copious vomiting, respiratory difficulty, chest pain, tachycardia, and hypotension. 1, 3
  • Severe reactions can include respiratory depression, cardiovascular collapse, arrhythmias, myocardial infarction, acute congestive heart failure, unconsciousness, convulsions, and potentially death. 3
  • Reactions may occur with alcohol consumption up to 14 days after the last disulfiram dose. 3
  • Mild reactions can occur when blood alcohol concentration reaches as little as 5-10 mg/dL in sensitive individuals, with full symptoms developing at 50 mg/dL and unconsciousness typically occurring at 125-150 mg/dL. 3

Neuropsychiatric Side Effects

  • Rare reports of psychosis and confusional states have been documented with disulfiram treatment. 4
  • Peripheral neuropathy and optic neuritis have been reported and are dose-related adverse effects. 4
  • Common less serious effects include tiredness, headache, and sleepiness. 4

Monitoring Requirements

  • Patients must immediately notify their physician of any early symptoms of hepatitis including fatigue, weakness, malaise, anorexia, nausea, vomiting, jaundice, or dark urine. 3
  • Baseline liver function tests should be obtained, followed by testing at 2-week intervals for the first 2 months, then at 3-6 month intervals thereafter. 5
  • Complete blood count and serum chemistries including liver function tests should be monitored regularly. 3
  • The standard recommendation of liver function tests at 10-14 days is insufficient given that most hepatotoxic reactions occur within 2 weeks to 2 months. 3, 5

Additional Precautions

  • Disulfiram should be used with extreme caution in patients with diabetes mellitus, hypothyroidism, epilepsy, cerebral damage, chronic and acute nephritis. 3
  • Patients with a history of rubber contact dermatitis should be evaluated for hypersensitivity to thiuram derivatives before receiving disulfiram. 3
  • Drug interactions occur with compounds utilizing the cytochrome P450 enzyme system. 4
  • Patients should not be exposed to ethylene dibromide or its vapors while taking disulfiram. 3

Critical Patient Education

  • Patients must be fully informed never to consume alcohol in any form including sauces, vinegars, cough mixtures, aftershave lotions, and back rubs. 3
  • Every patient should carry an identification card stating they are receiving disulfiram and describing likely reaction symptoms. 3
  • Disulfiram should never be administered to a patient in a state of alcohol intoxication or without their full knowledge. 3

References

1
Guideline

Disulfiram-Alcohol Reaction Management

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

2
Guideline

Acamprosate Safety in Liver Disease

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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