Blog | Thursday, May 15, 2014

QD: News Every Day--4 underused drugs may help with alcohol use disorders

Acamprosate and oral naltrexone show the strongest evidence for decreasing alcohol consumption among people with alcohol use disorders (AUD), according to a meta-analysis.

Less than 10% of patients who abuse alcohol receive medications to help reducing consumption, so researchers conducted a review and meta-analysis among 122 randomized trials and 1 cohort study totaling nearly 23,000 patients to evaluate the benefits and harms of medications.

Results appeared online May 14 at the Journal of the American Medical Association.

Most studies assessed acamprosate (27; n=7,519), naltrexone (53; n=9,140), or both. The number needed to treat (NNT) to prevent return to any drinking for acamprosate was 12 and for oral naltrexone (50 mg/d) was 20. The NNT to prevent return to heavy drinking was 12 for oral naltrexone (50 mg/d). Head-to-head trials have not established superiority of either medication, the authors noted.

For injectable naltrexone, meta-analyses found no association with return to any drinking (risk difference [RD], −0.04; 95% CI, −0.10 to 0.03) or heavy drinking (RD, −0.01; 95% CI, −0.14 to 0.13). There was an association with reduction in heavy drinking days (weighted mean difference [WMD], −4.6%; 95% CI, −8.5% to −0.56%).

Because disulfiram has been available since the 1950s, clinicians may be more familiar with it than naltrexone or acamprosate, the authors noted. However, well-controlled trials of disulfiram do not adequately support an association with preventing return to any drinking or improvement in other alcohol consumption outcomes.

Among medications used off-label, moderate evidence supports an association with improvement in some consumption outcomes for nalmefene (heavy drinking days per month: weighted mean difference [WMD], −2.0; 95% CI, −3.0 to −1.0; drinks per drinking day: WMD, −1.02; 95% CI, −1.77 to −0.28). For topiramate there was evidence of an improvement (percentage of heavy drinking days: WMD, −9.0%; 95% CI, −15.3% to −2.7%; drinks per drinking day: WMD, −1.0; 95% CI, −1.6 to −0.48).

For naltrexone the number needed to harm for withdrawal from trials due to adverse events was 48 (95% CI, 30 to 112). For nalmefene, the number needed to harm was 12 (95% CI, 7 to 50). Risk was not significantly increased for acamprosate or topiramate.

“When clinicians decide to use one of the medications, a number of factors may help with choosing which medication to prescribe, including the medication’s efficacy, administration frequency, cost, adverse events, and availability,” the authors conclude.

An editorial by Katharine A. Bradley, MD, MPH, ACP Member and a co-author noted, “By identifying 4 effective medications for AUD (naltrexone, acamprosate, topiramate, and nalmefene), the authors highlight treatment options for a common medical condition for which patient-centered care is not currently the norm. Patients with AUDs should be offered options, including medications, evidence-based behavioral treatments, and mutual support for recovery. Moreover, patients should expect shared decision making about the best options for them.”