The evidence supports acamprosate and oral naltrexone as first-line treatments. 

Despite the prevalence and morbidity of alcohol use disorder, pharmacotherapy for the disorder is under-utilised by primary care clinicians and by hospitalists (NEJM JW Gen Med Aug 1 2023 and Ann Intern Med 2023; 176: 1137-1139). Options include three medications that are US Food and Drug Administration-approved for alcohol use disorder (i.e. acamprosate, naltrexone and disulfiram) and several that are used off-label (e.g. topiramate, baclofen, gabapentin).

To compare these medications, researchers undertook a meta-analysis to evaluate 118 randomised outpatient trials with durations of at least 12 weeks. Key findings include the following:

• acamprosate and oral naltrexone (50 mg/day) decreased alcohol consumption. The numbers needed to treat (NNT) to prevent one person from returning to drinking was 11 for acamprosate and 18 for oral naltrexone. Both medications caused gastrointestinal side effects (more common with naltrexone). Injectable naltrexone decreased percentage of drinking days but did not prevent return to drinking
• topiramate reduced the percentage of drinking days, but the absolute decrease was small: about two fewer drinking days monthly. Evidence was insufficient to determine the effect on return to drinking. Topiramate was associated with cognitive dysfunction, dizziness, numbness or tingling, and taste abnormalities
• baclofen reduced returning to drinking (low-strength evidence) but caused dizziness and drowsiness
• disulfiram and gabapentin did not reduce alcohol consumption (based on limited evidence)
• evidence was insufficient to evaluate varenicline, ondansetron and prazosin.

Comment: Moderate-strength evidence supports acamprosate and oral naltrexone as first-line treatments for patients with alcohol use disorder. Acamprosate had the lowest NNT to prevent return to drinking and fewer side effects than naltrexone, but it carries a high pill burden (two tablets, three times daily). Some clinicians might be more familiar with the other drugs mentioned (e.g. gabapentin, topiramate, baclofen), but they have less evidence supporting efficacy and more potential side effects.

Molly S. Brett, MD, Assistant Professor of Medicine, University of Colorado, Boulder, USA.

McPheeters M, et al. Pharmacotherapy for alcohol use disorder: a systematic review and meta-analysis. JAMA 2023; 330: 1653-1665.

This summary is taken from the following Journal Watch titles: General Medicine, Ambulatory Medicine, Hospital Medicine, Psychiatry.