TABLE 4.
Relapse prevention medications and potential use in liver disease patients
| Medication | FDA approved | Metabolism and excretion | Starting and effective dose | Liver disease considerations |
|---|---|---|---|---|
| Disulfiram | Yes | M: hepatic E: 70% renal |
250–500 mg daily | Severe, sometimes fatal, DILI and/or acute liver failure requiring transplant. Reports of neuropathy and psychosis. Not recommended for use in liver disease. |
| Naltrexone | Yes | M: hepatic E: mostly renal, 2% fecal |
Start: 25 mg daily Effective dose: 50 mg daily orally; 380 mg intramuscularly monthly. |
Rare potential for hepatotoxicity, some documented elevations in liver enzymes but no known cases of liver failure. Can see drug and metabolite accumulation in advanced cirrhosis (Childs class B or C).63 Suggest oral formulation over intramuscular for those with cirrhosis. Interacts with opioids so ensure patient is not on narcotics before starting. Meta-analysis in AUD patients without liver disease showed moderate efficacy. |
| Acamprosate | Yes | M: no hepatic E: renal |
Start: 333 mg three times daily Effective dose: 666 mg orally 3 times daily |
No evidence of hepatotoxicity. Meta-analysis in AUD patients without known liver disease showed moderate efficacy. |
| Gabapentin | No | M: not hepatic E: 75% renal, 25% fecal |
Start: no clear starting dose recommended Effective dose: 900–1800 mg 3 times daily |
No hepatotoxicity. Theoretical abuse potential. Use with caution for those with HE. Dose reduce in renal failure. For those with chronic kidney disease, lower doses may be as effective. |
| Baclofen | No | M: limited hepatic E: renal |
Start: 5 mg 3 times daily for 3 days, then increase to target dose by 5 mg every 3 day increments Effective dose: 10–20 mg 3 times daily |
No evidence for direct hepatotoxicity but may precipitate HE. Has been tested in randomized trials in ALD patients 64–66 and other observational trials.67,68 Dose reduce in renal failure and avoid administering in end-stage renal disease. |
| Topiramate | No | M: limited hepatic E: renal |
Start: 25–50 mg daily. Increase in 25–50 mg increments weekly to effective dose goal. Effective dose: 300 mg daily |
No evidence for hepatotoxicity but could affect liver function. Could worsen/confound hepatic encephalopathy. Dose reductions in hepatic and renal impairment. Effective dose needed may be lower in those with more advanced liver or kidney disease. |
Abbreviations: ALD, alcohol-associated liver disease; AUD, alcohol use disorder; FDA, Food and Drug Administration.