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Difficulty: MediumSubstance-Related and Addictive Disorders

A 45-year-old man comes to the clinic seeking help to stop drinking alcohol. He states, "I have been drinking half a liter of vodka daily for the past two years, but my wife says she will leave me if I don't quit." The patient's last drink was 5 days ago, and he successfully completed a supervised inpatient alcohol detoxification program yesterday. He feels "very depressed" about his marital problems and asks for a medication to help his mood as well as his alcohol cravings. His medical history is significant for bipolar I disorder, for which he has not taken any medications for several years, and severe osteoarthritis of the right knee. Current medications include a fentanyl transdermal patch for chronic pain. Vital signs are within normal limits. Physical examination reveals a palpable liver edge 3 cm below the right costal margin. Laboratory studies show an aspartate aminotransferase (AST) of 115 U/L, an alanine aminotransferase (ALT) of 52 U/L, and a serum creatinine of 0.8 mg/dL. Which of the following is the most appropriate pharmacotherapy to help maintain alcohol abstinence in this patient?

  1. AcamprosateAnswer
  2. B
    Naltrexone
  3. C
    Disulfiram
  4. D
    Diazepam
  5. E
    Sertraline

Answer

Acamprosate is the most appropriate medication to help maintain alcohol abstinence in this patient because it is safe to use with concurrent opioid therapy and in the setting of hepatic impairment.
Acamprosate is a first-line pharmacotherapy for Alcohol Use Disorder that acts via modulation of NMDA and GABA receptors to reduce cravings. It is excreted entirely by the kidneys and is safe to use in patients with hepatic impairment (such as this patient's alcoholic liver disease). Importantly, it does not interact with opioid medications, making it safe for this patient who is using a fentanyl patch for chronic pain.

Step-by-Step Solution

1
Identify the primary clinical goal.
The patient needs maintenance pharmacotherapy for Alcohol Use Disorder (AUD) to prevent relapse after successful detoxification.
First-line therapies for AUD maintenance include naltrexone and acamprosate. Second-line includes disulfiram.
2
Assess patient's comorbidities and current medications.
The patient uses a fentanyl transdermal patch, has untreated bipolar I disorder, and exhibits laboratory signs of alcoholic liver disease (AST:ALT ratio > 2:1).
Comorbidities and medication interactions dictate which AUD pharmacotherapy is safe to prescribe.
3
Evaluate contraindications for first-line AUD agents.
Naltrexone is contraindicated due to concurrent fentanyl use. Disulfiram is relatively contraindicated due to active liver disease. Sertraline is contraindicated due to unmedicated bipolar disorder.
Recognizing absolute and relative contraindications prevents dangerous adverse events like precipitated withdrawal, hepatotoxicity, or manic episodes.
4
Select the most appropriate and safe agent.
Acamprosate is selected.
Acamprosate is cleared renally (patient's creatinine is normal at 0.8 mg/dL), does not block opioid receptors, and is safe in liver disease.

Key Concept

Acamprosate is a first-line pharmacotherapy for Alcohol Use Disorder that is preferred in patients with significant liver disease or those who require concurrent opioid therapy, as it is renally excreted and does not block opioid receptors.
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Topics

Substance-Related and Addictive Disorders

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