Jasmine Carpenter is a Mental Health Clinical Pharmacy Specialist; Danielle LaPrad and Yewande Dayo are Pharmacy Practice Residents; and Shannon DeGrote is a Clinical Pharmacy Specialist, all at the Washington DC VA Medical Center. Kasraie Williamson is a Pharmacy Resident at Memorial Regional Hospital in Hollywood, Florida. Correspondence: Jasmine Carpenter (jasmine.carpenter@va.gov)
Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
Common AEs include memory impairment, anorexia, fatigue, paresthesias, and somnolence.62 There is an increased risk of nephrolithiasis with topiramate administration; therefore, adequate hydration is crucial.49,59 Titration of topiramate to the target dose is suggested to limit AEs.35
Prior to initiating topiramate, the patient’s renal function should be assessed. In those with a CrCl < 70 mL/min the dose should be decreased by 50% and titrated more slowly.62
Gabapentin
Gabapentin is prescribed for the treatment of partial seizures and postherpetic neuralgia. In recent years, it has shown efficacy for treating other conditions, such as AUD. While its mechanism for this indication remains unclear, the inhibition of excitatory alpha-2-delta calcium channels and stimulation of inhibitory GABAA receptors by gabapentin is believed to decrease alcohol cravings, reduce anxiety, and increase abstinence.66
A 12-week, double-blind, randomized controlled trial demonstrated that oral gabapentin was more efficacious than was placebo for improving rates of abstinence, decreasing heavy drinking, and reducing alcohol cravings.67 Gabapentin may also serve as a good adjunctive option to naltrexone therapy either when naltrexone monotherapy fails or if a patient is complaining of sleep and mood disturbances with abstinence.67,68
Dosing and Formulations
Gabapentin should be titrated slowly to minimize AEs. It can be initiated at 300 mgon day 1 and increase by 300-mg increments. Doses of 900 to 1,800 mg per day have proven to be efficacious for the treatment of AUD.66,67 These proposed doses can be safely administered to most patients, but caution should be observed in elderly and patients with renal impairment.69,70
Warnings, Precautions, and AEs
The most common AEs for gabapentin include drowsiness, dizziness, and fatigue.69 Since it is renally cleared, renal function should be monitored at baseline and periodically during treatment. Gabapentin is not metabolized by liver enzymes and does not significantly interact with drugs that require hepatic metabolism.
Baclofen
Baclofen has generated attention as an unconventional treatment option for alcohol dependence. Its unique mechanism of action, which involves the activation of GABAB receptors and the subsequent inhibition of dopaminergic neurons, makes it useful for the treatment of AUD.71
A 12-week study evaluating the effectiveness and safety of baclofen for the maintenance of alcohol abstinence demonstrated that baclofen was more efficacious than placebo for increasing abstinence in patients with liver cirrhosis. In addition, there were more cumulative days of abstinence with baclofen use (62.8 days) vs placebo (30.8 days) in cirrhotic patients.72
Dosing and Formulations
There has been a range of doses studied for baclofen in the treatment of AUD. Studies indicate that initiating baclofen at 30 mg daily and increasing doses based on the patient’s clinical response is most effective.72 As a result, doses as high as 275 mg per day have been used for some patients.73 Baclofen is renally cleared; therefore, the dose should be adjusted in patients with renal impairment.74
Warnings, Precautions, and AEs
Some of the common AEs of baclofen include drowsiness, confusion, headache, and nausea. Due to its CNS depressant effects, baclofen should be used with caution in the elderly. Also, due to its potential to cause withdrawal symptoms, baclofen should not be discontinued abruptly.74,75 Baclofen is a safe option for patients with severe liver disease, due to its minimal hepatic metabolism.76
