Letters to the Editor
Medications for the Treatment of Alcohol Dependence
TO THE EDITOR: The article, "Medications for Treating Alcohol Dependence," in the November 1, 2005, issue of American Family Physician is a useful, comprehensive review of the pharmacotherapeutic options available for treating alcohol-dependent patients.1 Family physicians often are the first to diagnose alcohol dependence, and manage ongoing treatment of patients initially diagnosed by subspecialists. This article illustrates that alcohol dependence can be treated effectively using pharmacotherapy when combined with psychosocial interventions.1 However, I would like to add several clarifications and corrections.
The dosage of acamprosate (Campral) is incorrectly stated throughout the article and in Table 1 as being weight-based.1 The correct dosing regimen for acamprosate is two 333-mg enteric-coated tablets taken three times daily to achieve the full 1,998-mg per day dosage recommended by the U.S. Food and Drug Administration (FDA). Acamprosate at this dosage should be initiated after alcohol withdrawal (no gradual titration is necessary) and should be maintained in patients who relapse.
For disulfiram (Antabuse), Table 1 recommends a starting dosage of 250 mg per day and then increasing to 500 mg per day.1 Some patients do require higher doses of disulfiram to ensure the alcohol/disulfiram reaction; however, most patients do well with 250 mg per day. Maintaining the 250 mg per day dosage may lead to fewer toxicities and adverse events.
In the article,1 the data given for nalmefene (Revex) come from one of the two initial single-site randomized controlled trials (RCTs) that indicated therapeutic benefit for nalmefene.2 However, a more recent, larger, multisite RCT did not find evidence of efficacy for nalmefene.3
The reported data on ondansetron (Zofran) are accurate1 but are based on one study,4 as other RCTs in adults have yet to be conducted. Furthermore, the dosage of ondansetron given in Table 1 is not readily available to physicians.1
It is also important for physicians to be aware that a once-monthly injectable formulation of naltrexone (Vivitrol) was recently approved by the FDA for alcohol dependence.
The development of new pharmacologic agents with proven efficacy for alcohol dependence-acamprosate, naltrexone (ReVia), and long-acting naltrexone-is an important advance. Hopefully, family physicians will gain confidence in the use of these new pharmacotherapies to expand the treatment of alcohol dependence.
Author disclosure: Dr. Garbutt is on the advisory boards and the speakers bureaus for Alkermes, Inc. and Forest Laboratories, Inc., and has received grant funding from Alkermes, Inc., Forest Laboratories, Inc., and Bristol-Myers Squibb.
REFERENCES
1. Williams SH. Medications for treating alcohol dependence. Am Fam Physician 2005;72:1775-80.
2. Mason BJ, Salvato FR, Williams LD, Ritvo EC, Cutler RB. A double-blind, placebo-controlled study of oral nalmefene for alcohol dependence. Arch Gen Psychiatry 1999;56:719-24.
3. Anton RF, Pettinati H, Zweben A, Kranzler HR, Johnson B, Bohn MJ, et al. A multi-site dose ranging study of nalmefene in the treatment of alcohol dependence. J Clin Psychopharmacol 2004;24:421-8.
4. Johnson BA, Roache JD, Javors MA, DiClemente CC, Cloninger CR, Prihoda TJ, et al. Ondansetron for reduction of drinking among biologically predisposed alcoholic patients: a randomized controlled trial. JAMA 2000;284:963-71.
editor's note: This letter was sent to the authors of "Medications for Treating Alcohol Dependence," who declined to reply.
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