Table 2.

Medications for the Maintenance Treatment of Alcohol Use Disorder (AUD)

Medication	Acamprosate	Disulfiram	Naltrexone	Gabapentin	Topiramate
FDA Approval for AUD?	Yes	Yes	Yes	No	No
Indications and clinical pearls	For maintenance of abstinence from alcohol for patients who have completed detoxification and are abstinent from alcohol before beginning acamprosate Preferred in patients with hepatic impairment	For highly motivated patients who have completed detoxification Cravings are not reduced with disulfiram	Reduces alcohol cravings; can reduce the number of drinks that a daily drinker consumes Monthly injectable formulation may be helpful for compliance	Off label use: Moderate to severe alcohol use disorder May be helpful in mild alcohol withdrawal syndrome or patients with neuropathic pain	Off label use: Alcohol use disorder
Mechanism of action	Promotes balance between the excitatory and inhibitory neurotransmitters, glutamate and GABA	Disrupts the metabolism of alcohol by inhibiting enzyme aldehyde dehydrogenase causing an unpleasant physical reaction when combined with alcohol	Blocks opiate receptors that are involved in the rewarding effects of drinking and craving for alcohol	Calcium channel blocker and y-aminobutyric acid (GABA) modulator	Antagonizes excitatory neurotransmitters (glutamate) and decreases dopamine release in reward pathway
Dosing Note: For older patients, recommended to start low and go slow with dosing, but can titrate based on response and tolerability	666 mg PO TID 333 mg PO TID (for patients with renal impairment)	Start 125 mg PO daily (must be abstinent from alcohol >12 h), increase to 250 mg daily after several days Maintenance usually 250–500 mg daily	50 mg PO daily OR 380 mg IM (gluteal) q4 weeks Do not initiate therapy until patient is opioid-free for at least 7–10 days (by urinalysis).	Start 300 mg PO daily and increase dose in increments of 300 mg every 1–2 days up to a target dose of 600 mg three times a day	Start 25 mg PO daily and increase dose by 25 mg weekly Poor tolerability seen in patients on doses greater than 100 mg/day
Common side effects	Diarrhea (dose related, transient), weakness, peripheral edema, insomnia, anxiety	Skin eruptions (e.g., acne, allergic dermatitis), drowsiness, fatigue, impotence, headache, metallic taste	Headache, nausea, somnolence, vomiting	Drowsiness, fatigue, dizziness, stomach upset, dry mouth	Dose-related sedative effects (dizziness, drowsiness, fatigue) Stomach upset, decreased appetite, anorexia, weight reduction, increased anxiety, paresthesias
Contraindications and older adult considerations	Because of elevated risk of diminished renal function in people aged >65, baseline and frequent renal function tests (q3–6 months) are important in this population	Contraindicated in severe myocardial disease or coronary occlusion, psychoses, and in those with high levels of impulsivity, suicidality, and hypersensitivity to disulfiram or to other thiuram derivatives Risk of hepatic toxicity in otherwise healthy adults Counsel patient that any alcohol ingestion can result in reaction (e.g., cough syrups, mouthwash)	Can precipitate opioid withdrawal Do not use in patients with hepatitis or other liver dysfunction	Do not use in chronic kidney disease May cause respiratory depression in older adults Increased risk of falls due to somnolence Can exacerbate myasthenia gravis	Extended-release formulation contraindicated with recent alcohol use (6 h prior or after dose) and patients with metabolic acidosis with concomitant metformin use Risk of weight loss and short and long-term cognitive impairment (even at low doses, i.e., ≤100 mg/day) makes it not a first line treatment for AUD in older adults