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Oral Naltrexone and Acamprosate Reduce Various Measures of Alcohol Consumption

Summary and Comment |
May 13, 2014

Oral Naltrexone and Acamprosate Reduce Various Measures of Alcohol Consumption

  1. Thomas L. Schwenk, MD

Nalmefene and topiramate also are somewhat effective, but disulfiram is not.

  1. Thomas L. Schwenk, MD

A systemic review of 123 clinical studies (essentially all randomized, controlled trials; duration range, 12–52 weeks; 23,000 total patients) of FDA-approved medications and medications that are used off-label in patients with alcohol-use disorders (i.e., alcohol abuse or dependence) showed clinical value for four medications. Most patients were enrolled in these studies after detoxification or a period of sobriety. Most studies included a range of psychosocial interventions and support.

Acamprosate (a glutamine antagonist and γ-aminobutyric acid agonist) and oral naltrexone (an opioid antagonist) were about equally effective in preventing resumption of any drinking. Naltrexone also was effective in reducing heavy drinking, but acamprosate was not. The magnitude of effectiveness translates to needing to treat between 12 and 20 patients in order for 1 patient to benefit. Injectable naltrexone was associated with fewer heavy drinking days but did not affect other measures. Disulfiram (an acetaldehyde dehydrogenase inhibitor) did not reduce alcohol consumption.

Two off-label medications conferred clinical value. Nalmefene (Revex; an opioid antagonist) and topiramate (an anticonvulsant) were associated with improvements in various measures of heavy drinking. Researchers found insufficient or no evidence for using a wide range of off-label medications, including selective serotonin reuptake inhibitors, tricyclic antidepressants, atypical antipsychotics, and gabapentin.

Comment

Editorialists believe that these findings should encourage primary care clinicians to be more involved in caring for patients with alcohol-use disorders. Primary care physicians should realize that, because effective medications exist to supplement psychosocial interventions, they can engage patients more assertively in shared decision-making, take primary responsibility for managing mild-to-moderate alcohol-use disorder, and coordinate effective referrals for complex patients.

  • Disclosures for Thomas L. Schwenk, MD at time of publication Editorial boards UpToDate

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