A 55-year-old man comes to the primary care clinic seeking help to stop drinking alcohol. … — USMLE Step 2 CK

A $55$ -year-old man comes to the primary care clinic seeking help to stop drinking alcohol. He reports consuming approximately a pint of vodka daily for the past six years. He says, "I was hospitalized two weeks ago with liver problems, and it really scared me into wanting to quit for good." He has not consumed alcohol for the past three days and currently reports no symptoms of withdrawal. Medical history is significant for major depressive disorder and chronic hepatitis C virus infection. Review of laboratory studies from his recent hospitalization shows an aspartate aminotransferase (AST) of $345 \text{ U/L}$ , alanine aminotransferase (ALT) of $160 \text{ U/L}$ , and total bilirubin of $4.5 \text{ mg/dL}$ . His current medications include sertraline and a daily multivitamin. He requests a medication to help reduce his urge to drink. What is the most appropriate pharmacotherapy for this patient?

AcamprosateAnswer
B
Naltrexone
C
Disulfiram
D
Bupropion
E
Buprenorphine

Answer

The correct answer is acamprosate.

The correct option is acamprosate. This patient has severe alcohol use disorder and requires pharmacotherapy to maintain abstinence. The two primary first-line options are naltrexone and acamprosate. However, the patient's markedly elevated aminotransferases and bilirubin indicate severe, acute hepatic dysfunction on top of chronic hepatitis C. Acamprosate is a glutamate NMDA receptor modulator that is not metabolized by the liver; it is excreted unchanged by the kidneys. This makes it the safest and most appropriate choice for treating alcohol cravings in patients with significant liver disease.

Step-by-Step Solution

Identify the patient's primary request and underlying condition.

The patient has alcohol use disorder and is requesting pharmacotherapy to reduce cravings and maintain abstinence.

Establishing the diagnosis guides the selection of first-line maintenance therapies, which primarily include naltrexone and acamprosate.

Evaluate the patient's medical comorbidities and laboratory findings.

The patient has chronic hepatitis C with acute hepatic injury, indicated by markedly elevated transaminases (AST

345 \text{ U/L}

, ALT

160 \text{ U/L}

) and hyperbilirubinemia (

4.5 \text{ mg/dL}

Identifying comorbid conditions is critical, as many medications used for substance use disorders have organ-specific toxicity or contraindications.

Select the safest and most effective medication based on the patient's hepatic function.

Acamprosate is selected because it is renally excreted, whereas naltrexone and disulfiram are hepatotoxic and contraindicated in severe liver disease.

Acamprosate provides effective craving reduction while avoiding the risk of exacerbating the patient's acute hepatic dysfunction.

Key Concept

Acamprosate and naltrexone are first-line pharmacotherapies for alcohol use disorder. Acamprosate is renally excreted and is the preferred agent in patients with severe liver disease, whereas naltrexone is hepatotoxic and contraindicated in patients with acute hepatitis or liver failure.

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