MEDICATION TO PREVENT RELAPSE
Disulfiram acts through the inhibition of the hepatic metabolism of alcohol leading to an escalation of plasma acetaldehyde levels. The rationale of prescribing is one of 'aversive therapy'. The following symptoms may result following alcohol consumption:
- Flushing of the face.
- Pulsating headache.
- Vomiting.
- Breathing difficulties.
- Sweating and thirst.
- Blurred vision.
- Low blood pressure and dizziness.
- Confusion.
- The reaction may be fatal in rare instances.
EFFECTIVENESS
Despite its common-sense advantages there is a surprising lack of quality evidence demonstrating that disulfiram increases abstinence rates. Anecdotal reports suggest success in individual cases especially where a relative or carer is available to supervise daily administration.
SIDE EFFECT PROFILE
There are reports of occasional rashes, tremor, headache, dizziness, peripheral neuropathies and psychosis. There is some evidence that disulfiram may precipitate liver damage, and liver function tests should be performed on a 3 to 6 monthly basis. It is contraindicated in pregnancy and breast-feeding, patients with a history of cardiovascular (including hypertension) or cerebrovascular disorder and in hepatic and renal failure. It should also usually be avoided in patients with a history of deliberate self-harm.
The unpleasant reaction can sometimes be triggered by the presence of alcohol in liquid medicines, remedies, tonics, foods and toiletries - patients must be warned to avoid close contact with or consumption of anything containing alcohol (see appendix 9, page129).
DOSAGE AND INDUCTION
Prescribing is usually commenced with a bolus dose of 800mg orally, decreasing to a maintenance dose of between 100mg and 200mg daily thereafter. Disulfiram should not be commenced within 24 hours of the last drink, and it is advisable to perform a breathalyser test before induction. Continuation will usually be for a period of 6 months to one year.
CONCLUSION
In contrast to naltrexone and acamprosate, there is little evidence of disulfiram's effectiveness in preventing relapse, and there are often contraindications to its prescription evident in patients with chronic alcoholism. Nevertheless it remains appropriate for prescription in selected cases.
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The above information is copyright of Dr Bruce Trathen MBBS MRCPsych (2006). ISBN 0-9545164-0-0. The author grants permission for these guidelines to be downloaded, copied and distributed freely, but does not grant permission for their sale.
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