Which Agents Work Best: FDA Approved and Off-Label Medications Help Patients Achieve Abstinence and Maintain Sobriety

Historically, alcohol use disorder (AUD; classified as alcohol abuse or dependence in DSM-IV-TR) has been treated with psychosocial therapies, but many patients treated this way relapse into heavy drinking patterns and are unable to sustain sobriety (Box 1, page 24 (1)). Although vital for treating AUDI psychosocial methods have, to date, a modest success rate. Research has demonstrated that combining pharmacotherapy with psychosocial programs is effective for treating AUD. (2) [ILLUSTRATION OMITTED] Patients and clinicians might associate AUD medications with so-called aversion therapy because, for many years, the only treatment was disulfiram, which causes unpleasant physical effects when consumed with alcohol. However, newer medications help patients maintain abstinence by targeting brain neurotransmitters relevant to addiction neu-rocircuitry, such as dopamine, serotonin, [gamma]-aminobutyric acid (GABA), glutamate, and opioid. (3) These medications may help patients with AUD achieve sobriety, avoid relapse, decrease heavy drinking days, and delay time to recurrent drinking. In this article, we review FDA-approved medications (Table 1, page 25) (4-6) and off-label agents (Table 2, page 26) (3), (7-18) and provide recommendations for treating patients with AU]) (Box 2, page 28). (19-21) Table 1 FDA-approved medications for alcohol use disorders Medication Dosing Mechanism of Common side Relative action effects contraindications Naltrexone 50 to Mu receptor GI upset, Opioid use or (4) 100 blockade headache, opioid withdrawal, mg/d interrupts dizziness, severe liver reward nervousness, inflammation or pathways in fatigue cirrhosis the brain Acamprosate 666 to Modulate Diarrhea; Severe renal (5) 999 mg, overactive nervousness, impairment 3 times glutamatergic fatigue, daily brain activity insomnia, that occurs depression after stopping have been chronic heavy reported with alcohol use high doses Disulfiram 125 to Accumulation Nausea, Patients who (6) 500 of vomiting, recently received mg/d acetaldehyde hypertension metronidazole, in the blood if taken with paraldehyde, produces alcoho006C alcohol, or unpleasant alcohol-containing symptoms preparations; severe myocardial disease or coronary occlusion, and psychosis Table 2 Off-label medications for treating alcohol use disorders Medication Indication Mechanism of Dosing action Topiramate Migraine headaches, GABA-mediated 25 mg/d Impaired memory seizures neuronal and inhibition and increases antagonizes by 25 to certain 50 mg per glutamate day at receptor weekly subtypes intervals to a target of 300 mg/d in divided doses Baclofen Spasticity [GABA. …