Pharmacotherapy of alcoholism – an update on approved and off-label medications

ABSTRACT

Introduction: Only a few medications are available for the treatment of alcohol use disorders (AUDs).

Areas covered: This paper discusses approved AUD medications, including the opioid antagonists naltrexone and nalmefene (the latter is licensed for reduction of alcohol consumption only), the putative glutamate receptor antagonist acamprosate and the aldehyde dehydrogenase inhibitor disulfiram. It also covers off-label medications of interest, including topiramate, gabapentin, ondansetron, varenicline, baclofen, sodium oxybate and antidepressants. Clinical implications, benefits and risks of treatment are discussed.

Expert opinion: Acamprosate, naltrexone, nalmefene and disulfiram are the only approved ‘alcohol-specific’ drugs. Acamprosate and naltrexone have been evaluated in numerous clinical trials and represent evidence-based treatments in AUDs. Nalmefene use, however, is controversial. Supervised disulfiram is a second-line treatment approach. Compounds developed and licensed for different neuropsychiatric disorders are potential alternatives. Encouraging results have been reported for topiramate, gabapentin and also varenicline, which might be useful in patients with comorbid nicotine dependence. The GABA (γ-aminobutyric acid)-B receptor agonist baclofen has shown mixed results; it is currently licensed for the treatment of AUDs in France only. Gabapentin may be close to approval in the USA. Further studies of these novel treatment approaches in AUDs are needed.

KEYWORDS:

• Alcoholism
• pharmacotherapy
• acamprosate
• baclofen
• naltrexone
• nalmefene
• topiramate
• gabapentin
• disulfiram
• sodium oxybate

Article highlights

• Only a few drugs with clear evidence but modest effects are approved for treatment of AUDs, including naltrexone (oral, depot) and acamprosate.

• Supervised disulfiram administration represents a second-line treatment in AUDs.

• Nalmefene is approved for the reduction of alcohol intake, but its use is controversial.

• Encouraging results have been reported for topiramate, gabapentin and varenicline.

• Baclofen has shown mixed results; further studies are needed to evaluate baclofen and new formulations of this compound.

• Some recent unpublished studies have shown positive results for gabapentin and in the USA it may be close to approval for the treatment of AUDs.

• A ‘magic bullet’ is not in sight, but progress is being made.

This box summarizes key points contained in the article.

Acknowledgment

The authors thank Jacquie Klesing, Board-certified Editor in the Life Sciences (ELS), for editorial assistance with the manuscript.

Declaration of interest

For the past five years, M. Soyka has received research support and/or served as a consultant to Mepha, Lundbeck, Reckitt Benckiser/Invidior, Mundipharma, Servier and Sanofi-Aventis. C.A. Müller has received research grant support and speaker honoraria from Lundbeck. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Additional information

Funding

This paper was not funded.