Naltrexone and acamprosate are two commonly used medications for alcohol use disorder (AUD), but the ideal candidate for each medication is different. I will discuss the most important clinical practice pearls and nuggets that will likely show up on your board exam with naltrexone versus acamprosate.
Naltrexone: Think “Reduce Drinking”
Naltrexone is a particularly good option for patients who are still drinking and want to reduce their alcohol consumption or heavy drinking days. A major advantage is that patients do not need to be completely abstinent before starting naltrexone. Naltrexone is typically given as 50 mg once daily orally, with an extended-release injectable formulation also available. The extended-release injection formulation and once daily oral dosing give a nice distinction from acamprosate.
Before using naltrexone, consider:
- Does the patient use opioids? Naltrexone blocks opioid receptors and should not be used with current opioid use or opioid dependence.
- Does the patient have significant acute liver disease? Naltrexone should be avoided in acute hepatitis or hepatic failure.
- Would an injectable formulation improve adherence? If so, naltrexone could be helpful here.
A patient who is still drinking and wants to “cut back”, has decent liver function, and is not taking opioids is often a strong candidate for naltrexone.
Acamprosate: Think “Maintain Abstinence”
Acamprosate is particularly useful for patients who have already stopped drinking and want help maintaining abstinence. It is commonly dosed at 666 mg three times daily in patients with normal renal function. Frequent dosing is a downside.
Acamprosate is eliminated primarily through the kidneys and is not hepatically metabolized, making it an attractive option when liver disease is a concern.
Before using acamprosate, consider:
- Has the patient already achieved abstinence? If they have, this may favor the use of acamprosate.
- Is kidney function adequate? If yes, acamprosate is reasonable.
- Will the patient be able to manage three-times-daily dosing? If yes, acamprosate might be a good fit.
Acamprosate should be avoided in severe renal impairment and requires dose adjustment with moderate renal impairment.
In clinical practice, I see more naltrexone versus acamprosate. This can be due to a variety of factors, including liver and renal function, but the three-times-daily dosing of acamprosate is a challenge for a lot of patients.
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