While the guidelines for adequate liver function to initiate these medications is a matter of controversy, some clinicians recommend that liver enzymes should be twice the upper limit of normal or better, and that the medications should be stopped if liver function tests are 3 times the upper limit of normal or worse. Some clinicians use more liberal or conservative guidelines, although most recommend that an elevated bilirubin contraindicates the use of either agent.
Assuming that the patient is medically able to take either one, tell the patient that there are 2 medications approved for the treatment of alcohol dependence, and briefly describe each. Then ask the patient if he or she is potentially interested in either. Many patients will opt for no pharmacotherapy, some for naltrexone, and a smaller portion for disulfiram. This choice may vary over time, however, based on the patient’s clinical status. By remaining flexible and sharing this decision-making process with the patient, you increase the likelihood of medication compliance.
Current evidence suggests that both disulfiram and naltrexone are effective only in conjunction with alcohol-focused psychosocial treatment; this may include professional alcoholism treatment, support groups such as Alcoholics Anonymous, or, ideally, a combination of the two.
Monitoring compliance and side effects is also critical. By integrating pharmacologic and psychosocial approaches for alcohol-dependent patients, outcomes can be improved for this prevalent and highly treatable population.
Related resources
- The National Institute on Alcohol Abuse and Alcoholism (NIAAA) www.niaaa.nih.gov
- American Academy of Addiction Psychiatry (AAAP) www.aaap.org
- American Society of Addiction Medicine (ASAM) www.asam.org
Drug brand names
- Acamprosate • Campral
- Disulfiram • Antabuse
- Isoniazid • Laniazid, Nydrazid
- Naltrexone • ReVia
- Warfarin • Coumadin, Miradon
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article.