From the Guidelines
Disulfiram should not be started in patients with mild transaminitis due to the risk of hepatotoxicity, as recommended by the most recent guidelines 1.
Considerations for Disulfiram Use
When considering the use of disulfiram in patients with liver disease, it is essential to weigh the potential benefits against the risks. Disulfiram is known to inhibit aldehyde dehydrogenase and can cause hepatotoxicity in some patients, with rare cases of fulminant hepatitis reported 1.
Monitoring and Dosing
Although the standard dosing of disulfiram is typically 250-500 mg daily, starting at a lower dose may be prudent in patients with mild transaminitis, if disulfiram were to be considered at all. However, given the guidelines, this approach is not recommended. Liver function tests, including ALT, AST, alkaline phosphatase, bilirubin, and albumin, should be monitored frequently if treatment were to be initiated, despite the guidelines advising against it 1.
Alternative Treatments
Alternative treatments for alcohol use disorder, such as naltrexone, acamprosate, and baclofen, may be considered in patients with liver disease, as they have different mechanisms of action and safety profiles 1. Baclofen, in particular, has been shown to be effective in promoting alcohol abstinence in patients with alcoholic cirrhosis, with an acceptable safety profile 1.
Conclusion Not Applicable - Direct Answer Only
The most recent and highest quality study recommends against the use of disulfiram in patients with liver disease, including those with mild transaminitis 1.
- Key points to consider:
- Disulfiram can cause hepatotoxicity and should be avoided in patients with significant liver disease.
- Alternative treatments, such as baclofen, may be considered in patients with liver disease.
- Close monitoring of liver function tests is essential if disulfiram were to be used, despite the recommendation against it.
From the FDA Drug Label
Hepatic toxicity including hepatic failure resulting in transplantation or death have been reported Severe and sometimes fatal hepatitis associated with disulfiram therapy may develop even after many months of therapy. Hepatic toxicity has occurred in patients with or without prior history of abnormal liver function Baseline and follow-up liver function tests (10 to 14 days) are suggested to detect any hepatic dysfunction that may result with disulfiram therapy
Disulfiram can be associated with hepatic toxicity, including severe and sometimes fatal hepatitis. The drug label suggests monitoring liver function tests to detect any hepatic dysfunction. However, it does not provide explicit guidance on starting disulfiram in patients with mild transaminitis.
- The label does mention that hepatic toxicity has occurred in patients with or without a prior history of abnormal liver function.
- It is recommended to exercise caution when using disulfiram in patients with any condition that may increase the risk of hepatic toxicity.
- Given the potential risk of hepatic toxicity, it is prudent to carefully evaluate the risks and benefits before starting disulfiram in a patient with mild transaminitis 2.
From the Research
Disulfiram and Mild Transaminitis
- Disulfiram can be started in patients with mild transaminitis, but monitoring of liver function test results is warranted 3.
- A study found that most patients with moderately elevated transaminase levels can take disulfiram safely, but monitoring is necessary to detect any potential adverse consequences 3.
- However, another study suggests that disulfiram can cause severe drug-induced liver injury (DILI), especially in patients with underlying liver disease, and is associated with certain HLA alleles 4.
Definition of Mild Transaminitis
- Mildly elevated liver enzymes are defined as less than five times the upper limit of normal, but above the normal reference range 5.
- Screening patients with even mild elevations of transaminases can lead to early diagnosis of chronic hepatitis and better treatment outcomes 5.
Comparison with Other Medications
- Naltrexone, another medication for alcohol use disorder, has been found to be safe to use in patients with underlying liver disease, including those with compensated cirrhosis 6.
- Acamprosate and baclofen have also been studied for the treatment of alcohol use disorder, but disulfiram is the most commonly associated with DILI 4, 7.
Clinical Considerations
- Clinicians should be aware of the potential risks and benefits of disulfiram in patients with mild transaminitis and monitor liver function test results closely 3, 4.
- The decision to start disulfiram in patients with mild transaminitis should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history 3, 4.