In a 35‑year‑old man with alcoholic cardiomyopathy and cirrhosis who continues to drink, how should baclofen be started (initial low “wet” dose and titration) and what psychosocial support should be provided?

Starting Baclofen in Alcoholic Cirrhosis: Dosing and Psychosocial Support

In a patient with alcoholic cardiomyopathy and cirrhosis who continues to drink ("wet" dosing), baclofen should be initiated at 5 mg three times daily and titrated gradually based on response and tolerability, while simultaneously providing structured psychosocial interventions including motivational interviewing and regular follow-up. 1

Baclofen Initiation and Titration Protocol

Starting Dose in Active Drinkers ("Wet" Dosing)

• Begin with 5 mg three times daily (15 mg/day total) in patients who are still actively drinking 1
• Baclofen is unique among alcohol pharmacotherapies because it can be safely initiated while the patient is still consuming alcohol, unlike acamprosate which requires 3-7 days of abstinence before starting 2, 3
• This "wet" dosing approach is particularly important in cirrhotic patients who may struggle to achieve initial abstinence 4

Titration Strategy

• Increase the dose gradually by 5 mg increments every 3-7 days based on patient response and side effect tolerance 4
• Target maintenance dose typically ranges from 30-75 mg/day in divided doses (three times daily) 4, 1
• Some patients may require higher doses up to 210 mg/day, though this should be approached cautiously in cirrhotic patients 4
• The mean effective dose in real-world cirrhotic patients was 75 mg/day 4

Safety Considerations in Cirrhosis

• Baclofen is the only alcohol pharmacotherapy proven safe and effective in randomized controlled trials specifically in cirrhotic patients 2, 1
• The drug has minimal hepatic metabolism, making it particularly suitable for patients with liver disease 5
• In a landmark study, 71% of cirrhotic patients achieved abstinence on baclofen versus 29% on placebo, with no hepatic side effects recorded 1
• Common side effects include drowsiness (22% of patients), but no serious adverse events or overt encephalopathy related to baclofen have been reported in cirrhotic populations 4

Critical Caveat

• Avoid naltrexone entirely in this population due to hepatotoxicity risk 2, 3
• Disulfiram should also be avoided in severe alcoholic liver disease due to possible hepatotoxicity 2
• While acamprosate is safe in liver disease, it cannot be started until the patient achieves abstinence for 3-7 days, making it impractical for initial "wet" dosing 2, 3

Essential Psychosocial Support Components

Mandatory Psychosocial Framework

• Baclofen must always be combined with psychosocial interventions—pharmacotherapy alone is insufficient 4, 6
• The effectiveness of baclofen in real-world cirrhotic patients (57.7% still on treatment at 12 months, 40.8% achieving abstinence) was achieved specifically when combined with psychosocial care 4

Specific Psychosocial Interventions Required

Motivational Interviewing:

• Use a non-judgmental, non-confrontational approach that respects patient autonomy 2
• Apply the "Five A's" model at each visit: Ask about use, Advise to quit or reduce, Assess willingness, Assist to quit or reduce, and Arrange follow-up 2
• Present objective feedback based on clinical data (liver function tests, imaging findings) to increase awareness of alcohol-related consequences 2
• Adding a motivational component to brief interventions significantly improves efficacy 2

Structured Follow-Up Schedule:

• Schedule outpatient visits every 3 months minimum to assess alcohol consumption, medication adherence, and side effects 4
• More frequent visits (every 2-4 weeks initially) may be beneficial during the titration phase 4
• At each visit, assess total alcohol abstinence and cumulative abstinence duration 1

Counseling and Support Groups:

• Provide access to specialized alcohol counseling as part of comprehensive care 2
• Encourage participation in self-help groups (such as Alcoholics Anonymous), which is mandatory even in the post-transplant period if liver transplantation becomes necessary 6
• Psychosocial treatment should help patients understand and obtain insight into their alcohol use disorder 2

Monitoring Parameters During Treatment

• Track declared alcohol consumption at each visit using standardized measures 4
• Monitor biomarkers of alcohol intake: AST, GGT, and MCV typically improve with reduced consumption 4
• Assess liver function: Prothrombin time, albumin levels, and bilirubin should be monitored for improvement 4
• Define relapse clearly: More than 4 drinks per day or ≥14 drinks per week over at least 4 weeks 1

Treatment Duration

• Plan for at least 12 weeks of treatment as the minimum duration to assess effectiveness 1
• Continue treatment for 12 months or longer if the patient is responding well, as real-world data shows 73% of cirrhotic patients remained in follow-up at 12 months 4
• Treatment should be ongoing as long as it provides benefit in maintaining abstinence or reducing consumption 5

Clinical Pitfalls to Avoid

• Do not wait for complete abstinence before starting baclofen—this is a key advantage over acamprosate in actively drinking patients 2, 3
• Do not use baclofen as monotherapy—always combine with psychosocial interventions for optimal outcomes 4, 6
• Do not start at high doses—gradual titration minimizes side effects like drowsiness and improves adherence 4
• Do not assume all alcohol pharmacotherapies are safe in cirrhosis—only baclofen has proven safety data in this population 2, 1