4.10.1 Alcohol dependence

Advice from the Together Drugs and Alcohol Service regarding patients with alcohol dependence during the Coronavirus (COVID-19) pandemic can be found here.

Drugs used, not listed here:

See NICE CG115- Alcohol dependence and harmful alcohol use (February 2011)

Acamprosate, disulfiram and naltrexone are treatment options for motivated individuals with a diagnosis of moderate to severe alcohol dependence who have successfully withdrawn from alcohol.

Prescribing should be an adjunct to pharmacological therapy rather than an intervention in its own right.

Acamprosate
  • Tablets 333mg (£33.46 = 168 tablets)

Indications

  • Maintenance of abstinence in alcohol-dependent patients

Dose

  • Patient weighing less than 60kg
    • 666mg at breakfast, 333mg at midday and 333mg at night
  • Patient weighing 60kg and over
    • 666mg three times daily with meals

Notes

  1. Acamprosate is the treatment of choice owing to a more favourable side-effect profile and fewer problems with concurrent alcohol consumption.
  2. Acamprosate is useful for patients who are concerned that strong cravings will result in relapse. It should be initiated as soon as possible after abstinence has been achieved and continued for 1 year; treatment should be maintained if the patient has a temporary relapse.
  3. Acamprosate is not effective in all patients, so efficacy should be regularly assessed.
  4. Service users taking acamprosate should stay under supervision, at least monthly, for six months and at reduced but regular intervals if acamprosate is continued after six months (NICE Clinical Guideline CG115).
Disulfiram
  • Tablets 200mg (£91.73 = 50 tablets)

Indications

  • Adjuvant in the treatment of patients with drinking problems

Dose

  • 200mg daily increased if necessary. Usual maximum 500mg daily

Opioid receptor antagonists

Nalmefene
  • Tablets 18mg (£42.42 = 14 tablets)

Indications

  • Nalmefene should only be initiated by suitably trained clinicians, after appropriate psychosocial support is made available and has commenced.
  • Should be prescribed in line with NICE TA325: Nalmefene for reducing alcohol consumption in people with alcohol dependence (November 2014), where it is recommended for people who are:
    • Drinking more than 7.5 units (men) or 5 units (women) per day and
    • Do not have physical withdrawal symptoms and
    • Do not need to stop drinking immediately or completely
  • The SPC states that nalmefene should only be prescribed
    • In conjunction with psychosocial support focussed on treatment adherence and reducing alcohol consumption and
    • Should only be initiated in patients who continue to have a high drinking risk level two weeks after initial assessment

Dose

  • One tablet, preferably 1-2 hours prior to anticipated time of drinking or as soon as possible after starting.
  • The maximum dose is one tablet per day.

Notes

  • Nalmefene is contraindicated in the following groups:
    • patients taking opioid analgesics
    • current or recent opioid addiction
    • acute symptoms of opioid withdrawal
    • where recent opioid use is suspected
    • severe hepatic impairment
    • severe renal impairment (eGFR less than 30mL/min per 1.73m2)
    • patients with a recent history of acute alcohol withdrawal syndrome (including hallucinations, seizures, and delirium tremens)

 

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