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INTERNSHIP > Drugs for Alcohol Dependence > Flashcards

Drugs for Alcohol Dependence Flashcards

1
Q

What are 3 drugs used for alcohol dependence?

A
  1. Acamprosate
  2. Disulfiram
  3. Naltrexone
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2
Q

How is the dose of acamprosate determined?

A

Acamprosate dosing is weight-based. Patients under 60 kg take 666 mg in the morning, followed by 333 mg around midday and 333 mg at night. Patients over 60 kg take 666 mg three times daily.

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3
Q

Describe the drugs available for long-term management of alcohol dependence?

A

Three drugs with different modes of action may be used in treatment: disulfiram, acamprosate and naltrexone.

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4
Q

Give a brief overview of the use of acamprosate in the long-term management of alcohol dependence.

A

It may be hard to achieve compliance with acamprosate because of the need to take six tablets daily; however, it will not affect treatment for pain relief.

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5
Q

How does acamprosate work?

A

Acamprosate reduces the neuronal hyperexcitability characteristic of alcohol withdrawal.

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6
Q

In which setting is acamprosate used for alcohol withdrawal?

A

While it is not an effective treatment for the acute phase, acamprosate reduces the symptoms of protracted alcohol withdrawal

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7
Q

Describe the evidence for acamprosate

A

It has been shown to increase the time to first drink, prolong abstinence, and reduce the number of drinking days. Acamprosate combined with psychosocial treatment has been shown to significantly improve treatment outcomes when compared to psychosocial treatment alone.

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8
Q

When should acamprosate be initiated?

A

In conjunction with a counselling program, acamprosate should be started following cessation of the acute phase of alcohol withdrawal, (i.e. approximately 1 week after cessation of drinking)

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9
Q

What is the standard dosage of acamprosate in patients weighing less than 60 kg?

A

666 mg orally, in the morning, 333 mg at midday and 333 mg at night

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10
Q

What is the standard dosage of acamprosate in patients weighing 60 kg or more?

A

666 mg orally, 3 times daily.

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11
Q

Is supervision of dosing necessary with acamprosate?

A

Supervision of dosing should be encouraged.

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12
Q

Is there a risk of dependence associated with acamprosate?

A

There is no evidence of any potential for dependence with acamprosate.

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13
Q

Describe the clearance of acamprosate.

A

It is cleared by the kidneys hence is contraindicated where serum creatinine is greater than 120 micromol/L.

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14
Q

Describe the role of a combination of acamprosate and naltrexone

A

Some trials suggested that the combination of naltrexone and acamprosate may be more effective in preventing relapse than either drug alone. The combination is safe but is not yet recommended as a standard treatment. It would be reasonable to prescribe the combination when treatment with a single drug has not achieved the desired result.

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15
Q

What is the drug class of acamprosate?

A

Neuromediator, to maintain abstinence in alcohol dependence

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16
Q

What 3 Cautionary Advisory Labels are recommended with acamprosate?

A
  1. Label 2
  2. Label A
  3. Label B
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17
Q

How should patients use acamprosate?

A

It is generally recommended to take acamprosate continuously for one year. Patients should not stop taking it if they have a short relapse, or feel they don’t need to take it anymore.

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18
Q

What are 5 common side effects of acamprosate?

A
  1. Diarrhoea
  2. Abdominal pain
  3. Nausea/vomiting
  4. Rash
  5. Changes in libido
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19
Q

Describe the use of acamprosate in pregnancy.

A

Acamprosate is in pregnancy category B2, although is contraindicated in pregnancy

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20
Q

Describe the use of acamprosate in breastfeeding.

A

Acamprosate is contraindicated in breastfeeding

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21
Q

Describe the use of acamprosate in renal impairment.

A

Acamprosate is contraindicated in significant renal function (serum creatinine >120 µmol/L)

22
Q

What monitoring is recommended with acamprosate?

A

Monitor for changes in mood or behaviour suggestive of suicidal thoughts or depression, because of the association between alcohol dependence, depression and suicidality

23
Q

What is the mechanism of action of acamprosate?

A

Acamprosate has a chemical structure similar to GABA and taurine. Its true mechanism is unclear, possibly involves restoration of normal activity in glutamate and GABA-ergic systems.

24
Q

Describe the use of acamprosate in hepatic impairment.

A

The manufacturer contraindicates use in severe hepatic impairment (Child-Pugh class C) due to lack of data, however, acamprosate is not metabolised via the liver.

25
Q

Can acamprosate tablets be crushed/chewed?

A

No. It is not suitable for patients with enteral feeding tubes or swallowing difficulties.

26
Q

Give a brief overview of the use of disulfiram in the long-term management of alcohol dependence.

A

Disulfiram gives good results but treatment must be closely supervised.

27
Q

Disulfiram can give good results for which patient group in particular?

A

Highly motivated, physically fit individuals who are capable of compliance with an abstinence-based program.

28
Q

Describe the evidence for disulfiram.

A

Where disulfiram forms part of a structured therapeutic program including supervised dosing, outcomes have been good, for example, a reduction in the number of drinking days has been documented.

29
Q

What is it essential to ensure a patient understands about disulfiram?

A

Ensure that the patient understands they must not have any alcohol with the disulfiram.

30
Q

How should disulfiram be used in practice?

A

Dispense the disulfiram dose daily under supervision of a clinic or of a trusted person such as a spouse or employer.

31
Q

What is the standard regimen of disulfiram?

A

Disulfiram 100 mg orally, once daily initially for 1 to 2 weeks, increase as required and as tolerated up to 300 mg daily.

32
Q

Disulfiram should not be started unless what two conditions are satisfied?

A

Disulfiram should not be started unless the patient fully understands the risks involved and has not consumed alcohol in the previous 24 hours.

33
Q

How should disulfiram dose be increased?

A

Increase disulfiram dose slowly because people vary in the efficiency of their acetaldehyde dehydrogenase enzyme (which metabolises alcohol) so some are more sensitive to disulfiram’s effect than others.

34
Q

How does disulfiram interact with alcohol?

A

Disulfiram interacts with alcohol by blocking its metabolism.

35
Q

What occurs if a patient ingests alcohol while taking disulfiram?

A

Ingestion of alcohol results in a raised blood acetaldehyde concentration, giving rise to the aldehyde reaction

36
Q

What are 10 symptoms of the aldehyde reaction?

A
  1. Intense flushing
  2. Sweating
  3. Palpitations
  4. Tachycardia
  5. Dyspnoea
  6. Hyperventilation
  7. Pounding headache
  8. Chest pains (potentially)
  9. Restlessness (potentially)
  10. Sense of impending doom (potentially)
37
Q

Give a brief overview of the use of naltrexone in the long-term management of alcohol dependence.

A

Naltrexone can interfere with treatment for pain relief but dosing with one tablet daily may aid compliance.

38
Q

How does naltrexone work?

A

Naltrexone blocks the effect of endogenous opioids released following alcohol intake. As a result, the person who drinks alcohol reports less pleasurable effects, even though alcohol-induced impairment remains unaffected. Some studies report fewer cravings for alcohol.

39
Q

What group of patients may naloxone be most effective in and why?

A

Naltrexone may be most effective in patients with a history of binge drinking and those who have been drinking heavily as it reduces rate of relapse to heavy drinking and increases the number of abstinence days.

40
Q

Is naltrexone an appropriate option for patients with stable social support and living situation?

A

Yes

41
Q

What biological markers should be monitored with naltrexone?

A

Liver biochemistry should be assessed before beginning treatment and monitored according to the product information.

42
Q

What is the standard regimen for naltrexone in the management of alcohol dependence?

A

If considered appropriate and in conjunction with a psychosocial treatment program, use naltrexone 50 mg orally, once daily.

43
Q

What is a recommended way to help ensure compliance with naltrexone?

A

Supervision by a trusted person may help ensure compliance.

44
Q

Is there a risk of withdrawal syndrome with naltrexone when used for alcohol dependence?

A

Naltrexone does not precipitate a withdrawal syndrome in alcohol-dependent people who do not use opioids.

45
Q

Are there risks associated with combining alcohol and naltrexone?

A

There are no adverse effects from combining alcohol and naltrexone.

46
Q

What is a contraindication of naltrexone?

A

Naltrexone blocks the effect of opioid analgesics and is thus contraindicated in people who require chronic opioid therapy.

47
Q

What is the approach to acute pain management in patients who are use using naltrexone for alcohol dependence?

A

Acute pain relief can be provided by nonopioid drugs, such as nonsteroidal anti-inflammatory drugs (including parenteral ketorolac), or by using local or regional anaesthesia.

48
Q

Describe the blood pressure patterns in a patient experiencing the aldehyde reaction

A

There is an associated steep rise in blood pressure followed by hypotension.

49
Q

What damage may be caused by severe aldehyde reactions?

A

Severe reactions may have an effect on the heart, or be associated with seizures and loss of consciousness. Occasionally death may occur from cardiorespiratory failure.

50
Q

How are aldehyde reactions

treated?

A

Treatment of the interaction involves intensive supportive therapy.

INTERNSHIP (189 decks)

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