drugs used to prevent alcohol relapse can cause suicidal ideation - Acamprosate

[Guest guest]

Use of prescribed drugs to treat alcohol addiction

http://www.imt.ie/mims/2010/12/18344.html

December 1, 2010 By Emmanuelle Pinjon Leave a Comment

Alcohol-dependent patients might require medically prescribed drugs to help them in the initial stages of treatment or/and to prevent relapses.

The main types of drug used in the treatment of alcohol addiction are:

Detoxification

Chlordiazepoxide: Chlordiazepoxide is indicated for the management of alcohol withdrawal. It is a benzodiazepine used for the short-term (2-4 weeks) symptomatic treatment of severe and disabling anxiety, which is a common symptom during the withdrawal period. It is contraindicated in case of myasthenia gravis, severe respiratory insufficiency, sleep apnoea and severe hepatic insufficiency. Other benzodiazepines such as alprazolam are also indicated for anxiety, but like other benzodiazepines only when the disorder is severe, disabling or subjecting the individual to extreme distress.

Detoxification from alcohol dependence using another sedative such as benzodiazepines follows the same principle as detoxification from nicotine dependence using nicotine replacement or from opioid dependence using methadone or buprenorphine. However,in the treatment of patients dependent on alcohol or other sedatives, appropriate detoxification is particularly critical because the sedative withdrawal syndrome is potentially life-threatening.

Preventing relapse (see also Table 1)

Acamprosate is used to prevent relapse in recovering alcohol-dependent patients. Acamprosate is a synthetic analogue of taurine (a non-essential amino acid). It appears to restore the normal activity of glutaminergic neurons, which become hyperexcited as a result of chronic alcohol exposure*. Over the past two decades, the safety and efficacy of acamprosate for alcohol dependence have been well established in multiple double-blind, placebo-controlled trials. Patients treated with acamprosate report a significantly greater rate of complete abstinence, longer time to first drink, and increased duration of cumulative abstinence when compared with placebo. Reports indicate that acamprosate is effective in combination with counselling. It is contraindicated in cases of renal insufficiency or severe hepatic failure. Disulfiram: A patient taking disulfiram who drinks alcohol will suffer severe nausea and vomiting. The effect of disulfiram is primarily due to irreversible inactivation of liver ALDH. In the absence of this enzyme, the metabolism of ethanol is blocked and the intracellular acetaldehyde concentration rises. The high levels of acetaldehyde are partly responsible of the symptoms of the disulfiram-alcohol reaction. However, disulfiram will not have any effect on the system if it is not mixed with alcohol. This drug is only used in extreme cases and its success depends on the clients willingness to keep taking the drug. Disulfiram is contraindicated in the presence of decompensated cardiac disease, severe hypertension, psychoses. Naltrexone: Naltrexone is indicated for use in alcohol dependence to reduce the risk of relapse, support abstinence and reduce alcohol craving. It also reduces the feeling of intoxication if a person does relapse while taking the drug. Both naltrexone and acamprosate should be taken as part of a comprehensive addiction recovery programme. These drugs only deal with physical symptoms and do not treat the psychological causes of addiction. Naltrexone is contraindicated in case of acute hepatitis or liver failure as well as in patients who have a positive screen for opioids.

* Whereas the acute administration of alcohol and sedatives increases ã-aminobutyric acid (GABA) and decreases glutamate activation, the reverse occurs with chronic exposure, generating a GABA deficiency state and glutamate hyperactivity that increases the risk of seizures during withdrawal.

Table 1. Medications for Alcohol Dependence Treatment

Acamprosate

Disulfiram

Naltrexone

Action

Affects glutamate and GABA neurotransmitter systems.

Inhibits intermediate metabolism of alcohol causing a build up of acetaldehyde and a reaction of flushing, sweating, nausea and tachycardia if a patient drinks alcohol.

Blocks opioid receptors, resulting in reduced craving and reduced reward in response to drinking.

Contraindications

Severe renal impairment, severe hepatic failure. Pregnancy, lactation.

Cardiac failure, coronary artery disease, previous history of CVA, hypertension, severe personality disorder, suicidal risk, psychosis. Lactation. First trimester of pregnancy.

Current use of opioids or in acute opioid withdrawal, anticipated need for opioid analgesics, acute hepatitis or liver failure.

Precautions

Moderate renal impairment, depression or suicidal ideation and behaviour.

Hepatic cirrhosis or insufficiency, cerebrovascular disease or cerebral damage, psychoses (current or history), diabetes mellitus, epilepsy, hypothyroidism, renal impairment. Pregnancy.

Other hepatic disease, renal impairment, history of suicide attempts or depression. If opioid analgesia needed, larger doses may be required and respiratory depression may be deeper and more prolonged. Pregnancy.

Serious adverse reactions

Rare events include suicidal ideation and behaviour.

Disulfiram-alcohol reaction, hepatoxicity, optic neuritis, peripheral neuropathy, psychotic reactions.

Will precipitate severe withdrawal if patient is dependent on opioids, hepatotoxicity.

Common

side-effects

Diarrhoea, abdominal pain, vomiting, nausea, pruritus, maculo-papular rash, decreased libido.

Drowsiness, fatigue, headache, nausea, vomiting, halitosis, taste disorders, reduced libido.

Chest pain, abdominal pain/cramps, nausea and/or vomiting, diarrhoea, constipation, joint and muscle pain, delayed ejaculation, decreased potency, skin rash, Difficulty sleeping, anxiety, nervousness, head ache, feeling down, irritability, dizziness, increased lacrimation, low energy, loss of appetite, increased thirst, increased energy, chills, increased sweating.

Drug interactions

None known.

Not recommended: Alcohol or alcohol-containing preparations. Paraldehyde, phenytoin, amphetamines, morphine, diazepam, antipyrine, pethidine, rifampicin, chlordiazepoxide, courmarin anti-coagulants, metronidazole, isoniazid, chlorpromazine, amitriphyline, pimozide.

Opioid-containing medicines (contraindicated).

Adult dose

Over 60kg, 666mg three times daily.

Under 60kg, 666mg in the morning, 333mg at noon, 333mg at night.

Evaluate renal function and establish abstinence before prescribing.

On 1st day 800mg in one dose. Then 600mg (2nd day), 400mg (3rd day), 200mg (4th and 5th day). Subsequently 200mg or 100mg daily for up to 6 months maximum.

Before prescribing, evaluate liver function. Warn patient not to take disulfiram for at least 12 hours after drinking and that a disulfiram-alcohol reaction can occur up to 2 weeks after last dose. Warn patient to avoid alcohol in diet (e.g. sauces and vinegar), OTC medication (e.g. cough syrups) and toiletries (e.g. cologne, mouthwash).

Monitor liver function.

Initially, 25 mg daily; then, 50mg daily.

Before starting patients must be opioid-free for a minimum of 7-10 days. If there is a risk of precipitating an opioid withdrawal reaction, administer a naloxone challenge test. Evaluate liver function.

Monitor liver function.

Acamprosate

Disulfiram

Naltrexone

Action

Affects glutamate and GABA neurotransmitter systems.

Inhibits intermediate metabolism of alcohol causing a build up of acetaldehyde and a reaction of flushing, sweating, nausea and tachycardia if a patient drinks alcohol.

Blocks opioid receptors, resulting in reduced craving and reduced reward in response to drinking.

Contraindications

Severe renal impairment, severe hepatic failure. Pregnancy, lactation.

Cardiac failure, coronary artery disease, previous history of CVA, hypertension, severe personality disorder, suicidal risk, psychosis. Lactation. First trimester of pregnancy.

Current use of opioids or in acute opioid withdrawal, anticipated need for opioid analgesics, acute hepatitis or liver failure.

Precautions

Moderate renal impairment, depression or suicidal ideation and behaviour.

Hepatic cirrhosis or insufficiency, cerebrovascular disease or cerebral damage, psychoses (current or history), diabetes mellitus, epilepsy, hypothyroidism, renal impairment. Pregnancy.

Other hepatic disease, renal impairment, history of suicide attempts or depression. If opioid analgesia needed, larger doses may be required and respiratory depression may be deeper and more prolonged. Pregnancy.

Serious adverse reactions

Rare events include suicidal ideation and behaviour.

Disulfiram-alcohol reaction, hepatoxicity, optic neuritis, peripheral neuropathy, psychotic reactions.

Will precipitate severe withdrawal if patient is dependent on opioids, hepatotoxicity.

Common

side-effects

Diarrhoea, abdominal pain, vomiting, nausea, pruritus, maculo-papular rash, decreased libido.

Drowsiness, fatigue, headache, nausea, vomiting, halitosis, taste disorders, reduced libido.

Chest pain, abdominal pain/cramps, nausea and/or vomiting, diarrhoea, constipation, joint and muscle pain, delayed ejaculation, decreased potency, skin rash, Difficulty sleeping, anxiety, nervousness, head ache, feeling down, irritability, dizziness, increased lacrimation, low energy, loss of appetite, increased thirst, increased energy, chills, increased sweating.

Drug interactions

None known.

Not recommended: Alcohol or alcohol-containing preparations. Paraldehyde, phenytoin, amphetamines, morphine, diazepam, antipyrine, pethidine, rifampicin, chlordiazepoxide, courmarin anti-coagulants, metronidazole, isoniazid, chlorpromazine, amitriphyline, pimozide.

Opioid-containing medicines (contraindicated).

Adult dose

Over 60kg, 666mg three times daily.

Under 60kg, 666mg in the morning, 333mg at noon, 333mg at night.

Evaluate renal function and establish abstinence before prescribing.

On 1st day 800mg in one dose. Then 600mg (2nd day), 400mg (3rd day), 200mg (4th and 5th day). Subsequently 200mg or 100mg daily for up to 6 months maximum.

Before prescribing, evaluate liver function. Warn patient not to take disulfiram for at least 12 hours after drinking and that a disulfiram-alcohol reaction can occur up to 2 weeks after last dose. Warn patient to avoid alcohol in diet (e.g. sauces and vinegar), OTC medication (e.g. cough syrups) and toiletries (e.g. cologne, mouthwash).

Monitor liver function.

Initially, 25 mg daily; then, 50mg daily.

Before starting patients must be opioid-free for a minimum of 7-10 days. If there is a risk of precipitating an opioid withdrawal reaction, administer a naloxone challenge test. Evaluate liver function.

Monitor liver References: 1- Helping patients who drink too much. A clinicians guide. Updated 2005 Edition. U.S. Department of Health and Human Services. National Institutes of Health. National Institute on Alcohol Abuse and Alcoholism.

2- Campral EC. Summary of Product Characteristics. May 2007.

3- Antabuse. Summary of Product Characteristics. September 2007.

4- Nalorex. Summary of Product Characteristics. September 2009.

[Guest guest]

Use of prescribed drugs to treat alcohol addiction

http://www.imt.ie/mims/2010/12/18344.html

December 1, 2010 By Emmanuelle Pinjon Leave a Comment

Alcohol-dependent patients might require medically prescribed drugs to help them in the initial stages of treatment or/and to prevent relapses.

The main types of drug used in the treatment of alcohol addiction are:

Detoxification

Chlordiazepoxide: Chlordiazepoxide is indicated for the management of alcohol withdrawal. It is a benzodiazepine used for the short-term (2-4 weeks) symptomatic treatment of severe and disabling anxiety, which is a common symptom during the withdrawal period. It is contraindicated in case of myasthenia gravis, severe respiratory insufficiency, sleep apnoea and severe hepatic insufficiency. Other benzodiazepines such as alprazolam are also indicated for anxiety, but like other benzodiazepines only when the disorder is severe, disabling or subjecting the individual to extreme distress.

Detoxification from alcohol dependence using another sedative such as benzodiazepines follows the same principle as detoxification from nicotine dependence using nicotine replacement or from opioid dependence using methadone or buprenorphine. However,in the treatment of patients dependent on alcohol or other sedatives, appropriate detoxification is particularly critical because the sedative withdrawal syndrome is potentially life-threatening.

Preventing relapse (see also Table 1)

Acamprosate is used to prevent relapse in recovering alcohol-dependent patients. Acamprosate is a synthetic analogue of taurine (a non-essential amino acid). It appears to restore the normal activity of glutaminergic neurons, which become hyperexcited as a result of chronic alcohol exposure*. Over the past two decades, the safety and efficacy of acamprosate for alcohol dependence have been well established in multiple double-blind, placebo-controlled trials. Patients treated with acamprosate report a significantly greater rate of complete abstinence, longer time to first drink, and increased duration of cumulative abstinence when compared with placebo. Reports indicate that acamprosate is effective in combination with counselling. It is contraindicated in cases of renal insufficiency or severe hepatic failure. Disulfiram: A patient taking disulfiram who drinks alcohol will suffer severe nausea and vomiting. The effect of disulfiram is primarily due to irreversible inactivation of liver ALDH. In the absence of this enzyme, the metabolism of ethanol is blocked and the intracellular acetaldehyde concentration rises. The high levels of acetaldehyde are partly responsible of the symptoms of the disulfiram-alcohol reaction. However, disulfiram will not have any effect on the system if it is not mixed with alcohol. This drug is only used in extreme cases and its success depends on the clients willingness to keep taking the drug. Disulfiram is contraindicated in the presence of decompensated cardiac disease, severe hypertension, psychoses. Naltrexone: Naltrexone is indicated for use in alcohol dependence to reduce the risk of relapse, support abstinence and reduce alcohol craving. It also reduces the feeling of intoxication if a person does relapse while taking the drug. Both naltrexone and acamprosate should be taken as part of a comprehensive addiction recovery programme. These drugs only deal with physical symptoms and do not treat the psychological causes of addiction. Naltrexone is contraindicated in case of acute hepatitis or liver failure as well as in patients who have a positive screen for opioids.

* Whereas the acute administration of alcohol and sedatives increases ã-aminobutyric acid (GABA) and decreases glutamate activation, the reverse occurs with chronic exposure, generating a GABA deficiency state and glutamate hyperactivity that increases the risk of seizures during withdrawal.

Table 1. Medications for Alcohol Dependence Treatment

Acamprosate

Disulfiram

Naltrexone

Action

Affects glutamate and GABA neurotransmitter systems.

Inhibits intermediate metabolism of alcohol causing a build up of acetaldehyde and a reaction of flushing, sweating, nausea and tachycardia if a patient drinks alcohol.

Blocks opioid receptors, resulting in reduced craving and reduced reward in response to drinking.

Contraindications

Severe renal impairment, severe hepatic failure. Pregnancy, lactation.

Cardiac failure, coronary artery disease, previous history of CVA, hypertension, severe personality disorder, suicidal risk, psychosis. Lactation. First trimester of pregnancy.

Current use of opioids or in acute opioid withdrawal, anticipated need for opioid analgesics, acute hepatitis or liver failure.

Precautions

Moderate renal impairment, depression or suicidal ideation and behaviour.

Hepatic cirrhosis or insufficiency, cerebrovascular disease or cerebral damage, psychoses (current or history), diabetes mellitus, epilepsy, hypothyroidism, renal impairment. Pregnancy.

Other hepatic disease, renal impairment, history of suicide attempts or depression. If opioid analgesia needed, larger doses may be required and respiratory depression may be deeper and more prolonged. Pregnancy.

Serious adverse reactions

Rare events include suicidal ideation and behaviour.

Disulfiram-alcohol reaction, hepatoxicity, optic neuritis, peripheral neuropathy, psychotic reactions.

Will precipitate severe withdrawal if patient is dependent on opioids, hepatotoxicity.

Common

side-effects

Diarrhoea, abdominal pain, vomiting, nausea, pruritus, maculo-papular rash, decreased libido.

Drowsiness, fatigue, headache, nausea, vomiting, halitosis, taste disorders, reduced libido.

Chest pain, abdominal pain/cramps, nausea and/or vomiting, diarrhoea, constipation, joint and muscle pain, delayed ejaculation, decreased potency, skin rash, Difficulty sleeping, anxiety, nervousness, head ache, feeling down, irritability, dizziness, increased lacrimation, low energy, loss of appetite, increased thirst, increased energy, chills, increased sweating.

Drug interactions

None known.

Not recommended: Alcohol or alcohol-containing preparations. Paraldehyde, phenytoin, amphetamines, morphine, diazepam, antipyrine, pethidine, rifampicin, chlordiazepoxide, courmarin anti-coagulants, metronidazole, isoniazid, chlorpromazine, amitriphyline, pimozide.

Opioid-containing medicines (contraindicated).

Adult dose

Over 60kg, 666mg three times daily.

Under 60kg, 666mg in the morning, 333mg at noon, 333mg at night.

Evaluate renal function and establish abstinence before prescribing.

On 1st day 800mg in one dose. Then 600mg (2nd day), 400mg (3rd day), 200mg (4th and 5th day). Subsequently 200mg or 100mg daily for up to 6 months maximum.

Before prescribing, evaluate liver function. Warn patient not to take disulfiram for at least 12 hours after drinking and that a disulfiram-alcohol reaction can occur up to 2 weeks after last dose. Warn patient to avoid alcohol in diet (e.g. sauces and vinegar), OTC medication (e.g. cough syrups) and toiletries (e.g. cologne, mouthwash).

Monitor liver function.

Initially, 25 mg daily; then, 50mg daily.

Before starting patients must be opioid-free for a minimum of 7-10 days. If there is a risk of precipitating an opioid withdrawal reaction, administer a naloxone challenge test. Evaluate liver function.

Monitor liver function.

Acamprosate

Disulfiram

Naltrexone

Action

Affects glutamate and GABA neurotransmitter systems.

Inhibits intermediate metabolism of alcohol causing a build up of acetaldehyde and a reaction of flushing, sweating, nausea and tachycardia if a patient drinks alcohol.

Blocks opioid receptors, resulting in reduced craving and reduced reward in response to drinking.

Contraindications

Severe renal impairment, severe hepatic failure. Pregnancy, lactation.

Cardiac failure, coronary artery disease, previous history of CVA, hypertension, severe personality disorder, suicidal risk, psychosis. Lactation. First trimester of pregnancy.

Current use of opioids or in acute opioid withdrawal, anticipated need for opioid analgesics, acute hepatitis or liver failure.

Precautions

Moderate renal impairment, depression or suicidal ideation and behaviour.

Hepatic cirrhosis or insufficiency, cerebrovascular disease or cerebral damage, psychoses (current or history), diabetes mellitus, epilepsy, hypothyroidism, renal impairment. Pregnancy.

Other hepatic disease, renal impairment, history of suicide attempts or depression. If opioid analgesia needed, larger doses may be required and respiratory depression may be deeper and more prolonged. Pregnancy.

Serious adverse reactions

Rare events include suicidal ideation and behaviour.

Disulfiram-alcohol reaction, hepatoxicity, optic neuritis, peripheral neuropathy, psychotic reactions.

Will precipitate severe withdrawal if patient is dependent on opioids, hepatotoxicity.

Common

side-effects

Diarrhoea, abdominal pain, vomiting, nausea, pruritus, maculo-papular rash, decreased libido.

Drowsiness, fatigue, headache, nausea, vomiting, halitosis, taste disorders, reduced libido.

Chest pain, abdominal pain/cramps, nausea and/or vomiting, diarrhoea, constipation, joint and muscle pain, delayed ejaculation, decreased potency, skin rash, Difficulty sleeping, anxiety, nervousness, head ache, feeling down, irritability, dizziness, increased lacrimation, low energy, loss of appetite, increased thirst, increased energy, chills, increased sweating.

Drug interactions

None known.

Not recommended: Alcohol or alcohol-containing preparations. Paraldehyde, phenytoin, amphetamines, morphine, diazepam, antipyrine, pethidine, rifampicin, chlordiazepoxide, courmarin anti-coagulants, metronidazole, isoniazid, chlorpromazine, amitriphyline, pimozide.

Opioid-containing medicines (contraindicated).

Adult dose

Over 60kg, 666mg three times daily.

Under 60kg, 666mg in the morning, 333mg at noon, 333mg at night.

Evaluate renal function and establish abstinence before prescribing.

On 1st day 800mg in one dose. Then 600mg (2nd day), 400mg (3rd day), 200mg (4th and 5th day). Subsequently 200mg or 100mg daily for up to 6 months maximum.

Before prescribing, evaluate liver function. Warn patient not to take disulfiram for at least 12 hours after drinking and that a disulfiram-alcohol reaction can occur up to 2 weeks after last dose. Warn patient to avoid alcohol in diet (e.g. sauces and vinegar), OTC medication (e.g. cough syrups) and toiletries (e.g. cologne, mouthwash).

Monitor liver function.

Initially, 25 mg daily; then, 50mg daily.

Before starting patients must be opioid-free for a minimum of 7-10 days. If there is a risk of precipitating an opioid withdrawal reaction, administer a naloxone challenge test. Evaluate liver function.

Monitor liver References: 1- Helping patients who drink too much. A clinicians guide. Updated 2005 Edition. U.S. Department of Health and Human Services. National Institutes of Health. National Institute on Alcohol Abuse and Alcoholism.

2- Campral EC. Summary of Product Characteristics. May 2007.

3- Antabuse. Summary of Product Characteristics. September 2007.

4- Nalorex. Summary of Product Characteristics. September 2009.

[Guest guest]

Use of prescribed drugs to treat alcohol addiction

http://www.imt.ie/mims/2010/12/18344.html

December 1, 2010 By Emmanuelle Pinjon Leave a Comment

Alcohol-dependent patients might require medically prescribed drugs to help them in the initial stages of treatment or/and to prevent relapses.

The main types of drug used in the treatment of alcohol addiction are:

Detoxification

Chlordiazepoxide: Chlordiazepoxide is indicated for the management of alcohol withdrawal. It is a benzodiazepine used for the short-term (2-4 weeks) symptomatic treatment of severe and disabling anxiety, which is a common symptom during the withdrawal period. It is contraindicated in case of myasthenia gravis, severe respiratory insufficiency, sleep apnoea and severe hepatic insufficiency. Other benzodiazepines such as alprazolam are also indicated for anxiety, but like other benzodiazepines only when the disorder is severe, disabling or subjecting the individual to extreme distress.

Detoxification from alcohol dependence using another sedative such as benzodiazepines follows the same principle as detoxification from nicotine dependence using nicotine replacement or from opioid dependence using methadone or buprenorphine. However,in the treatment of patients dependent on alcohol or other sedatives, appropriate detoxification is particularly critical because the sedative withdrawal syndrome is potentially life-threatening.

Preventing relapse (see also Table 1)

Acamprosate is used to prevent relapse in recovering alcohol-dependent patients. Acamprosate is a synthetic analogue of taurine (a non-essential amino acid). It appears to restore the normal activity of glutaminergic neurons, which become hyperexcited as a result of chronic alcohol exposure*. Over the past two decades, the safety and efficacy of acamprosate for alcohol dependence have been well established in multiple double-blind, placebo-controlled trials. Patients treated with acamprosate report a significantly greater rate of complete abstinence, longer time to first drink, and increased duration of cumulative abstinence when compared with placebo. Reports indicate that acamprosate is effective in combination with counselling. It is contraindicated in cases of renal insufficiency or severe hepatic failure. Disulfiram: A patient taking disulfiram who drinks alcohol will suffer severe nausea and vomiting. The effect of disulfiram is primarily due to irreversible inactivation of liver ALDH. In the absence of this enzyme, the metabolism of ethanol is blocked and the intracellular acetaldehyde concentration rises. The high levels of acetaldehyde are partly responsible of the symptoms of the disulfiram-alcohol reaction. However, disulfiram will not have any effect on the system if it is not mixed with alcohol. This drug is only used in extreme cases and its success depends on the clients willingness to keep taking the drug. Disulfiram is contraindicated in the presence of decompensated cardiac disease, severe hypertension, psychoses. Naltrexone: Naltrexone is indicated for use in alcohol dependence to reduce the risk of relapse, support abstinence and reduce alcohol craving. It also reduces the feeling of intoxication if a person does relapse while taking the drug. Both naltrexone and acamprosate should be taken as part of a comprehensive addiction recovery programme. These drugs only deal with physical symptoms and do not treat the psychological causes of addiction. Naltrexone is contraindicated in case of acute hepatitis or liver failure as well as in patients who have a positive screen for opioids.

* Whereas the acute administration of alcohol and sedatives increases ã-aminobutyric acid (GABA) and decreases glutamate activation, the reverse occurs with chronic exposure, generating a GABA deficiency state and glutamate hyperactivity that increases the risk of seizures during withdrawal.

Table 1. Medications for Alcohol Dependence Treatment

Acamprosate

Disulfiram

Naltrexone

Action

Affects glutamate and GABA neurotransmitter systems.

Inhibits intermediate metabolism of alcohol causing a build up of acetaldehyde and a reaction of flushing, sweating, nausea and tachycardia if a patient drinks alcohol.

Blocks opioid receptors, resulting in reduced craving and reduced reward in response to drinking.

Contraindications

Severe renal impairment, severe hepatic failure. Pregnancy, lactation.

Cardiac failure, coronary artery disease, previous history of CVA, hypertension, severe personality disorder, suicidal risk, psychosis. Lactation. First trimester of pregnancy.

Current use of opioids or in acute opioid withdrawal, anticipated need for opioid analgesics, acute hepatitis or liver failure.

Precautions

Moderate renal impairment, depression or suicidal ideation and behaviour.

Hepatic cirrhosis or insufficiency, cerebrovascular disease or cerebral damage, psychoses (current or history), diabetes mellitus, epilepsy, hypothyroidism, renal impairment. Pregnancy.

Other hepatic disease, renal impairment, history of suicide attempts or depression. If opioid analgesia needed, larger doses may be required and respiratory depression may be deeper and more prolonged. Pregnancy.

Serious adverse reactions

Rare events include suicidal ideation and behaviour.

Disulfiram-alcohol reaction, hepatoxicity, optic neuritis, peripheral neuropathy, psychotic reactions.

Will precipitate severe withdrawal if patient is dependent on opioids, hepatotoxicity.

Common

side-effects

Diarrhoea, abdominal pain, vomiting, nausea, pruritus, maculo-papular rash, decreased libido.

Drowsiness, fatigue, headache, nausea, vomiting, halitosis, taste disorders, reduced libido.

Chest pain, abdominal pain/cramps, nausea and/or vomiting, diarrhoea, constipation, joint and muscle pain, delayed ejaculation, decreased potency, skin rash, Difficulty sleeping, anxiety, nervousness, head ache, feeling down, irritability, dizziness, increased lacrimation, low energy, loss of appetite, increased thirst, increased energy, chills, increased sweating.

Drug interactions

None known.

Not recommended: Alcohol or alcohol-containing preparations. Paraldehyde, phenytoin, amphetamines, morphine, diazepam, antipyrine, pethidine, rifampicin, chlordiazepoxide, courmarin anti-coagulants, metronidazole, isoniazid, chlorpromazine, amitriphyline, pimozide.

Opioid-containing medicines (contraindicated).

Adult dose

Over 60kg, 666mg three times daily.

Under 60kg, 666mg in the morning, 333mg at noon, 333mg at night.

Evaluate renal function and establish abstinence before prescribing.

On 1st day 800mg in one dose. Then 600mg (2nd day), 400mg (3rd day), 200mg (4th and 5th day). Subsequently 200mg or 100mg daily for up to 6 months maximum.

Before prescribing, evaluate liver function. Warn patient not to take disulfiram for at least 12 hours after drinking and that a disulfiram-alcohol reaction can occur up to 2 weeks after last dose. Warn patient to avoid alcohol in diet (e.g. sauces and vinegar), OTC medication (e.g. cough syrups) and toiletries (e.g. cologne, mouthwash).

Monitor liver function.

Initially, 25 mg daily; then, 50mg daily.

Before starting patients must be opioid-free for a minimum of 7-10 days. If there is a risk of precipitating an opioid withdrawal reaction, administer a naloxone challenge test. Evaluate liver function.

Monitor liver function.

Acamprosate

Disulfiram

Naltrexone

Action

Affects glutamate and GABA neurotransmitter systems.

Inhibits intermediate metabolism of alcohol causing a build up of acetaldehyde and a reaction of flushing, sweating, nausea and tachycardia if a patient drinks alcohol.

Blocks opioid receptors, resulting in reduced craving and reduced reward in response to drinking.

Contraindications

Severe renal impairment, severe hepatic failure. Pregnancy, lactation.

Cardiac failure, coronary artery disease, previous history of CVA, hypertension, severe personality disorder, suicidal risk, psychosis. Lactation. First trimester of pregnancy.

Current use of opioids or in acute opioid withdrawal, anticipated need for opioid analgesics, acute hepatitis or liver failure.

Precautions

Moderate renal impairment, depression or suicidal ideation and behaviour.

Hepatic cirrhosis or insufficiency, cerebrovascular disease or cerebral damage, psychoses (current or history), diabetes mellitus, epilepsy, hypothyroidism, renal impairment. Pregnancy.

Other hepatic disease, renal impairment, history of suicide attempts or depression. If opioid analgesia needed, larger doses may be required and respiratory depression may be deeper and more prolonged. Pregnancy.

Serious adverse reactions

Rare events include suicidal ideation and behaviour.

Disulfiram-alcohol reaction, hepatoxicity, optic neuritis, peripheral neuropathy, psychotic reactions.

Will precipitate severe withdrawal if patient is dependent on opioids, hepatotoxicity.

Common

side-effects

Diarrhoea, abdominal pain, vomiting, nausea, pruritus, maculo-papular rash, decreased libido.

Drowsiness, fatigue, headache, nausea, vomiting, halitosis, taste disorders, reduced libido.

Chest pain, abdominal pain/cramps, nausea and/or vomiting, diarrhoea, constipation, joint and muscle pain, delayed ejaculation, decreased potency, skin rash, Difficulty sleeping, anxiety, nervousness, head ache, feeling down, irritability, dizziness, increased lacrimation, low energy, loss of appetite, increased thirst, increased energy, chills, increased sweating.

Drug interactions

None known.

Not recommended: Alcohol or alcohol-containing preparations. Paraldehyde, phenytoin, amphetamines, morphine, diazepam, antipyrine, pethidine, rifampicin, chlordiazepoxide, courmarin anti-coagulants, metronidazole, isoniazid, chlorpromazine, amitriphyline, pimozide.

Opioid-containing medicines (contraindicated).

Adult dose

Over 60kg, 666mg three times daily.

Under 60kg, 666mg in the morning, 333mg at noon, 333mg at night.

Evaluate renal function and establish abstinence before prescribing.

On 1st day 800mg in one dose. Then 600mg (2nd day), 400mg (3rd day), 200mg (4th and 5th day). Subsequently 200mg or 100mg daily for up to 6 months maximum.

Before prescribing, evaluate liver function. Warn patient not to take disulfiram for at least 12 hours after drinking and that a disulfiram-alcohol reaction can occur up to 2 weeks after last dose. Warn patient to avoid alcohol in diet (e.g. sauces and vinegar), OTC medication (e.g. cough syrups) and toiletries (e.g. cologne, mouthwash).

Monitor liver function.

Initially, 25 mg daily; then, 50mg daily.

Before starting patients must be opioid-free for a minimum of 7-10 days. If there is a risk of precipitating an opioid withdrawal reaction, administer a naloxone challenge test. Evaluate liver function.

Monitor liver References: 1- Helping patients who drink too much. A clinicians guide. Updated 2005 Edition. U.S. Department of Health and Human Services. National Institutes of Health. National Institute on Alcohol Abuse and Alcoholism.

2- Campral EC. Summary of Product Characteristics. May 2007.

3- Antabuse. Summary of Product Characteristics. September 2007.

4- Nalorex. Summary of Product Characteristics. September 2009.

[Guest guest]

Use of prescribed drugs to treat alcohol addiction

http://www.imt.ie/mims/2010/12/18344.html

December 1, 2010 By Emmanuelle Pinjon Leave a Comment

Alcohol-dependent patients might require medically prescribed drugs to help them in the initial stages of treatment or/and to prevent relapses.

The main types of drug used in the treatment of alcohol addiction are:

Detoxification

Chlordiazepoxide: Chlordiazepoxide is indicated for the management of alcohol withdrawal. It is a benzodiazepine used for the short-term (2-4 weeks) symptomatic treatment of severe and disabling anxiety, which is a common symptom during the withdrawal period. It is contraindicated in case of myasthenia gravis, severe respiratory insufficiency, sleep apnoea and severe hepatic insufficiency. Other benzodiazepines such as alprazolam are also indicated for anxiety, but like other benzodiazepines only when the disorder is severe, disabling or subjecting the individual to extreme distress.

Detoxification from alcohol dependence using another sedative such as benzodiazepines follows the same principle as detoxification from nicotine dependence using nicotine replacement or from opioid dependence using methadone or buprenorphine. However,in the treatment of patients dependent on alcohol or other sedatives, appropriate detoxification is particularly critical because the sedative withdrawal syndrome is potentially life-threatening.

Preventing relapse (see also Table 1)

Acamprosate is used to prevent relapse in recovering alcohol-dependent patients. Acamprosate is a synthetic analogue of taurine (a non-essential amino acid). It appears to restore the normal activity of glutaminergic neurons, which become hyperexcited as a result of chronic alcohol exposure*. Over the past two decades, the safety and efficacy of acamprosate for alcohol dependence have been well established in multiple double-blind, placebo-controlled trials. Patients treated with acamprosate report a significantly greater rate of complete abstinence, longer time to first drink, and increased duration of cumulative abstinence when compared with placebo. Reports indicate that acamprosate is effective in combination with counselling. It is contraindicated in cases of renal insufficiency or severe hepatic failure. Disulfiram: A patient taking disulfiram who drinks alcohol will suffer severe nausea and vomiting. The effect of disulfiram is primarily due to irreversible inactivation of liver ALDH. In the absence of this enzyme, the metabolism of ethanol is blocked and the intracellular acetaldehyde concentration rises. The high levels of acetaldehyde are partly responsible of the symptoms of the disulfiram-alcohol reaction. However, disulfiram will not have any effect on the system if it is not mixed with alcohol. This drug is only used in extreme cases and its success depends on the clients willingness to keep taking the drug. Disulfiram is contraindicated in the presence of decompensated cardiac disease, severe hypertension, psychoses. Naltrexone: Naltrexone is indicated for use in alcohol dependence to reduce the risk of relapse, support abstinence and reduce alcohol craving. It also reduces the feeling of intoxication if a person does relapse while taking the drug. Both naltrexone and acamprosate should be taken as part of a comprehensive addiction recovery programme. These drugs only deal with physical symptoms and do not treat the psychological causes of addiction. Naltrexone is contraindicated in case of acute hepatitis or liver failure as well as in patients who have a positive screen for opioids.

* Whereas the acute administration of alcohol and sedatives increases ã-aminobutyric acid (GABA) and decreases glutamate activation, the reverse occurs with chronic exposure, generating a GABA deficiency state and glutamate hyperactivity that increases the risk of seizures during withdrawal.

Table 1. Medications for Alcohol Dependence Treatment

Acamprosate

Disulfiram

Naltrexone

Action

Affects glutamate and GABA neurotransmitter systems.

Inhibits intermediate metabolism of alcohol causing a build up of acetaldehyde and a reaction of flushing, sweating, nausea and tachycardia if a patient drinks alcohol.

Blocks opioid receptors, resulting in reduced craving and reduced reward in response to drinking.

Contraindications

Severe renal impairment, severe hepatic failure. Pregnancy, lactation.

Cardiac failure, coronary artery disease, previous history of CVA, hypertension, severe personality disorder, suicidal risk, psychosis. Lactation. First trimester of pregnancy.

Current use of opioids or in acute opioid withdrawal, anticipated need for opioid analgesics, acute hepatitis or liver failure.

Precautions

Moderate renal impairment, depression or suicidal ideation and behaviour.

Hepatic cirrhosis or insufficiency, cerebrovascular disease or cerebral damage, psychoses (current or history), diabetes mellitus, epilepsy, hypothyroidism, renal impairment. Pregnancy.

Other hepatic disease, renal impairment, history of suicide attempts or depression. If opioid analgesia needed, larger doses may be required and respiratory depression may be deeper and more prolonged. Pregnancy.

Serious adverse reactions

Rare events include suicidal ideation and behaviour.

Disulfiram-alcohol reaction, hepatoxicity, optic neuritis, peripheral neuropathy, psychotic reactions.

Will precipitate severe withdrawal if patient is dependent on opioids, hepatotoxicity.

Common

side-effects

Diarrhoea, abdominal pain, vomiting, nausea, pruritus, maculo-papular rash, decreased libido.

Drowsiness, fatigue, headache, nausea, vomiting, halitosis, taste disorders, reduced libido.

Chest pain, abdominal pain/cramps, nausea and/or vomiting, diarrhoea, constipation, joint and muscle pain, delayed ejaculation, decreased potency, skin rash, Difficulty sleeping, anxiety, nervousness, head ache, feeling down, irritability, dizziness, increased lacrimation, low energy, loss of appetite, increased thirst, increased energy, chills, increased sweating.

Drug interactions

None known.

Not recommended: Alcohol or alcohol-containing preparations. Paraldehyde, phenytoin, amphetamines, morphine, diazepam, antipyrine, pethidine, rifampicin, chlordiazepoxide, courmarin anti-coagulants, metronidazole, isoniazid, chlorpromazine, amitriphyline, pimozide.

Opioid-containing medicines (contraindicated).

Adult dose

Over 60kg, 666mg three times daily.

Under 60kg, 666mg in the morning, 333mg at noon, 333mg at night.

Evaluate renal function and establish abstinence before prescribing.

On 1st day 800mg in one dose. Then 600mg (2nd day), 400mg (3rd day), 200mg (4th and 5th day). Subsequently 200mg or 100mg daily for up to 6 months maximum.

Before prescribing, evaluate liver function. Warn patient not to take disulfiram for at least 12 hours after drinking and that a disulfiram-alcohol reaction can occur up to 2 weeks after last dose. Warn patient to avoid alcohol in diet (e.g. sauces and vinegar), OTC medication (e.g. cough syrups) and toiletries (e.g. cologne, mouthwash).

Monitor liver function.

Initially, 25 mg daily; then, 50mg daily.

Before starting patients must be opioid-free for a minimum of 7-10 days. If there is a risk of precipitating an opioid withdrawal reaction, administer a naloxone challenge test. Evaluate liver function.

Monitor liver function.

Acamprosate

Disulfiram

Naltrexone

Action

Affects glutamate and GABA neurotransmitter systems.

Inhibits intermediate metabolism of alcohol causing a build up of acetaldehyde and a reaction of flushing, sweating, nausea and tachycardia if a patient drinks alcohol.

Blocks opioid receptors, resulting in reduced craving and reduced reward in response to drinking.

Contraindications

Severe renal impairment, severe hepatic failure. Pregnancy, lactation.

Cardiac failure, coronary artery disease, previous history of CVA, hypertension, severe personality disorder, suicidal risk, psychosis. Lactation. First trimester of pregnancy.

Current use of opioids or in acute opioid withdrawal, anticipated need for opioid analgesics, acute hepatitis or liver failure.

Precautions

Moderate renal impairment, depression or suicidal ideation and behaviour.

Hepatic cirrhosis or insufficiency, cerebrovascular disease or cerebral damage, psychoses (current or history), diabetes mellitus, epilepsy, hypothyroidism, renal impairment. Pregnancy.

Other hepatic disease, renal impairment, history of suicide attempts or depression. If opioid analgesia needed, larger doses may be required and respiratory depression may be deeper and more prolonged. Pregnancy.

Serious adverse reactions

Rare events include suicidal ideation and behaviour.

Disulfiram-alcohol reaction, hepatoxicity, optic neuritis, peripheral neuropathy, psychotic reactions.

Will precipitate severe withdrawal if patient is dependent on opioids, hepatotoxicity.

Common

side-effects

Diarrhoea, abdominal pain, vomiting, nausea, pruritus, maculo-papular rash, decreased libido.

Drowsiness, fatigue, headache, nausea, vomiting, halitosis, taste disorders, reduced libido.

Chest pain, abdominal pain/cramps, nausea and/or vomiting, diarrhoea, constipation, joint and muscle pain, delayed ejaculation, decreased potency, skin rash, Difficulty sleeping, anxiety, nervousness, head ache, feeling down, irritability, dizziness, increased lacrimation, low energy, loss of appetite, increased thirst, increased energy, chills, increased sweating.

Drug interactions

None known.

Not recommended: Alcohol or alcohol-containing preparations. Paraldehyde, phenytoin, amphetamines, morphine, diazepam, antipyrine, pethidine, rifampicin, chlordiazepoxide, courmarin anti-coagulants, metronidazole, isoniazid, chlorpromazine, amitriphyline, pimozide.

Opioid-containing medicines (contraindicated).

Adult dose

Over 60kg, 666mg three times daily.

Under 60kg, 666mg in the morning, 333mg at noon, 333mg at night.

Evaluate renal function and establish abstinence before prescribing.

On 1st day 800mg in one dose. Then 600mg (2nd day), 400mg (3rd day), 200mg (4th and 5th day). Subsequently 200mg or 100mg daily for up to 6 months maximum.

Before prescribing, evaluate liver function. Warn patient not to take disulfiram for at least 12 hours after drinking and that a disulfiram-alcohol reaction can occur up to 2 weeks after last dose. Warn patient to avoid alcohol in diet (e.g. sauces and vinegar), OTC medication (e.g. cough syrups) and toiletries (e.g. cologne, mouthwash).

Monitor liver function.

Initially, 25 mg daily; then, 50mg daily.

Before starting patients must be opioid-free for a minimum of 7-10 days. If there is a risk of precipitating an opioid withdrawal reaction, administer a naloxone challenge test. Evaluate liver function.

Monitor liver References: 1- Helping patients who drink too much. A clinicians guide. Updated 2005 Edition. U.S. Department of Health and Human Services. National Institutes of Health. National Institute on Alcohol Abuse and Alcoholism.

2- Campral EC. Summary of Product Characteristics. May 2007.

3- Antabuse. Summary of Product Characteristics. September 2007.

4- Nalorex. Summary of Product Characteristics. September 2009.