A 46-year-old woman with alcohol use disorder comes to the office for follow-up. The patient has a prolonged history of heavy alcohol use and was hospitalized 6 months ago due to alcohol-induced pancreatitis. She stopped drinking after the hospitalization but restarted following a fight with her husband a month ago. Her daughters convinced her to stop again, and she has had no drinks for the past 2 weeks. The patient reports no anxiety or shakiness but has had occasional cravings and is afraid that she may relapse again. She has no other medical conditions, takes no medications, and does not use tobacco or illicit drugs. Vital signs are within normal limits, and physical examination shows no abnormalities. In addition to psychosocial interventions, which of the following is the most appropriate pharmacotherapy for this patient?

Question

A 46-year-old woman with alcohol use disorder comes to the office for follow-up.  The patient has a prolonged history of heavy alcohol use and was hospitalized 6 months ago due to alcohol-induced pancreatitis.  She stopped drinking after the hospitalization but restarted following a fight with her husband a month ago.  Her daughters convinced her to stop again, and she has had no drinks for the past 2 weeks.  The patient reports no anxiety or shakiness but has had occasional cravings and is afraid that she may relapse again.  She has no other medical conditions, takes no medications, and does not use tobacco or illicit drugs.  Vital signs are within normal limits, and physical examination shows no abnormalities.  In addition to psychosocial interventions, which of the following is the most appropriate pharmacotherapy for this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d77a_f819_bc81_41757555a003_MD0003_00 Patients with moderate to severe alcohol use disorder (AUD) should be offered pharmacotherapy in addition to psychosocial interventions. Medications that target the reinforcing effects of alcohol by modulating opioid and glutamate function have been shown to decrease cravings, reduce alcohol consumption, and help maintain abstinence. Acamprosate, a glutamate modulator at metabotropic glutamate receptor 5, is a first-line treatment that would help reduce this patient's risk of relapse. It is excreted mostly unchanged by the kidneys, and can be used safely in patients with liver disease, but requires dosage adjustment in patients with renal failure. Naltrexone, a mu-opioid receptor antagonist, is another first-line option for AUD. However, it has been associated with hepatotoxicity and is contraindicated in patients with liver disease and those taking prescribed opioid medication. (Choice B) Benzodiazepines (eg, chlordiazepoxide) are indicated for the treatment of moderate to severe alcohol withdrawal. They do not treat AUD and have a high risk of abuse. This patient has been abstinent for 2 weeks and shows no signs of withdrawal. (Choice C) Disulfiram, an aldehyde dehydrogenase inhibitor, is an aversive agent that causes an unpleasant physiologic reaction (eg, tachycardia, flushed skin, headache, nausea, vomiting) when alcohol is consumed. Candidates for disulfiram must be highly motivated or supervised because they may skip a dose to avoid the averse reaction when alcohol is desired. It is considered a second-line agent for use when naltrexone and acamprosate are either ineffective or contraindicated. (Choice D) Fomepizole is an alcohol dehydrogenase inhibitor used as an antidote to treat methanol or ethylene glycol poisoning. (Choice E) Naloxone is a short-acting opioid antagonist used to treat acute opioid intoxication. Educational objective: A combination of psychosocial interventions and pharmacotherapy is indicated for patients with moderate to severe alcohol use disorder. Acamprosate and naltrexone are first-line medication options. References: Acamprosate: a review of its use in alcohol dependence. (http://www.ncbi.nlm.nih.gov/pubmed/26084940) Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/24825644) Practical outpatient pharmacotherapy for alcohol use disorder. (http://www.ncbi.nlm.nih.gov/pubmed/29445407)

A 46-Year-Old Woman with Alcohol Use Disorder Comes to the Office