Amber with Guidance= To be initiated and titrated to a stable dose in secondary care with follow up prescribing and monitoring by primary care where deemed appropriate.
Disulfiram
Background Information / Disulfiram is used as an adjunct in the treatment of alcohol dependence. It gives rise to an extremely unpleasant systemic reaction after the ingestion of even a small amount of alcohol because it causes accumulation of acetaldehyde in the body; it is only effective if taken daily. Symptoms can occur within 10 minutes of ingesting alcohol and include flushing of the face, throbbing headache, palpitation, tachycardia, nausea, vomiting, and, with large doses of alcohol, arrhythmias, hypotension, and collapse; these reactions can last several hours. Small amounts of alcohol such as those included in many oral medicines may be sufficient to precipitate a reaction—even toiletries and mouthwashes that contain alcohol should be avoided. If this reaction occurs the patient should seek medical advice and a reaction should be treated in hospital.Alcohol should be avoided for at least 1 week after stopping treatment.
Before initiating disulfiram, prescribers should evaluate the patient’s suitability for treatment, because some patient factors, for example memory impairment or social circumstances, make compliance to treatment or abstinence from alcohol difficult.
BNF therapeutic class / 4.10. Drugs used in substance dependence
Indication / Maintenance of abstinence in alcohol dependence
Dosage and administration / The standard dose is 200mg daily.
There is no need for a loading dose to start treatment. The treatment is usually continued for approximately 6 – 12 months but some patients wish to continue for longer. There is no reason why disulfiram cannot be continued if well tolerated.
Cautions and Contraindications / The following are cautions to disulfiram and require discussion with the team, the prescriber and the patient in balancing the risk and benefits of treatment.
· Liver disease
· Moderately elevated liver function tests (approx. 5x above normal)
· Epilepsy
· Diabetes
Contraindications:
· Cardiac failure
· Coronary artery disease
· History of stroke
· Hypertension (uncontrolled)
· Psychosis
· High suicidal risk
· Renal failure
· Pregnancy or breast feeding
· Severe Personality Disorder
Contra-indications are not absolute. There will be cases where the known risks of continuing to drink alcohol will outweigh the potential risk of prescribing. If prescribing goes ahead after assessing the risks/benefits, reasons should be clearly documented.
Adverse Drug Reactions / Side-effects: These are usually mild and transient. The most common are gastro-intestinal symptoms.
Side Effect
/Suggested Action
Drowsiness/fatigue / Take at night, usually lessensNausea/vomiting / Take after food
Halitosis / Ensure dental hygiene
Sexual dysfunction/lack of libido / Discuss with doctor, may be another cause
Mood changes / Discuss
Impaired liver function / Need to monitor LFT, may need to discontinue
Monitoring / Initiation and initial monitoring should be by a specialist service (Specialist Alcohol Team or Shared care GP practices). Patients should be seen every 2 weeks for the first 2 months, then monthly for the following 4 months. During a review it is advisable to breathalyse the patient before giving a supervised dose of disulfiram. It is desirable for a carer or family member who is aware of the use of disulfiram to oversee its administration.
It is recommended that the liver function count is checked 1-2 months after starting treatment (specialist responsibility) and then every 6 months if within normal parameters.
See Appendix A for Disulfiram checklist used in the specialist service.
Interactions / Important to check reactions in BNF with:
· Warfarin
· Phenytoin
· Benzodiazepines – metabolism is inhibited, increasing sedative effect
· Amitriptyline and other tricyclic antidepressants
· Metronidazole
Contact names and details
Contact Details / Telephone number / EmailDr Fleur Ashby, Consultant Psychiatrist / 01226 434052 /
Chris Lawson, Head of Medicines Optimisation, NHS Barnsley Clinical Commissioning Group / 01226 433798 /
Sarah Hudson, Lead Pharmacist, SWYPFT
Medicines Information / 01226 434649 /
References
· British National Formulary. September 2013. Available at: www.bnf.org Accessed 24.06.14
· Disulfiram (Antabuse®) Summary of Product Characteristics. September 2008. http://www.medicines.org.uk/EMC/medicine/519/SPC/Antabuse+Tablets++200mg/ Accessed 24.06.14
· Alcohol - Use Disorders. Diagnosis, assessment and management of harmful drinking and alcohol dependence. NICE Clinical Guideline 115. February 2011. Available at: http://guidance.nice.org.uk/CG115 24.06.14
Appendix A
DISULFIRAM CHECK LIST
(To be used prior to commencement of prescription)
Client Name Date
Unit No Janus No
(1) How long ago was last drink of alcohol?
(2) Alcometer reading
MUST BE ZERO TO CONTINUE
(3) Check recent LFT’s and U & E’s
MUST BE DONE IN LAST 2 WEEKS TO CONTINUE
MUST BE WITHIN APPROVED RANGES TO CONTINUE
(less than approximately x 5 normal)
(4) Comment on patient’s motivation to remain abstinent
(5) Does the patient understand the disulfiram – alcohol reaction?
(i) Ensure they understand what the symptoms of a reaction are
and what action to take.
(ii) Ensure they understand and have information about foodstuffs, toiletries etc containing alcohol and have information about alternatives.
(iii) Ensure they understand the length of time disulfiram lasts
in the body and the implications of this.
(6) Check no contra indications to prescription.
Y N
(i) History of stroke
(ii) History of myocardial infarction
(iii) History of cardiac failure
(iv) Uncontrolled hypertension
(v) Psychosis
(vi) High suicide risk
(vii) Pregnancy
(viii) Breast feeding
(ix) Personality Disorder
MUST ANSWER NO TO ALL OF THESE TO CONTINUE
IF YES TO ANY THEN MUST BE SEEN BY DOCTOR
(7) Check no other drugs prescribed which interact with disulfiram
(Common ones are: benzodiazepines, warfarin, phenytoin, amitriptyline, metronidazole. Check others in BNF)
(8) Explain common side effects:
(drowsiness, fatigue, nausea, vomiting, halitosis, reduced libido)
(9) Explain action required if serious side effects develop
(1) rash – stop medication and attend review appointment.
(2) jaundice and/or liver pain – stop medication and seek
urgent medical advice.
(10) Who will supervise medication?
(11) Agree and arrange follow up plan
Follow up appointment made?
(Every 2 weeks for the first 2 months then monthly for following 4 months)
Doctors review appointment six monthly.
Name Signed
(Please print)
Page 1 of 4
Acamprosate Guidance
Date Prepared: July 2014 Review Date: July 2016