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Dr. Salsitz:
This is CME on ReachMD. And I'm Dr. Edwin Salsitz. Here with me today is Dr. Ethan Cowan.

Disulfiram is an older second-line drug use for alcohol use disorder. Dr. Cowan, where does this drug fit into therapy?

Dr. Cowan: 
Yes, disulfiram is a really interesting drug. We don't use it very often, and I would say that I don't see many patients who are using this in the outpatient setting, but it certainly is a possibility for some individuals. I think the decision to use the disulfiram really comes down to a shared decision-making process with the patient.

One of the reasons that we're not using it that much, at least in our population, is that we still have patients who are actively drinking. And of course, with disulfiram the patients have to be really completely abstinent, because if they drink while they're using the drug, they're going to get quite sick.

The other reason that we tend to not use this as much is that patients that we're seeing predominantly are still dependent on alcohol, and disulfiram is only recommended for patients who have already completed or generally completed a detox program so that they're not at risk for alcohol withdrawal.

One of the concerns that we have, I think, is the need for this success in this study is really related a lot to supervision particularly getting family and friends involved. And that's something that's difficult for us to do, at least from the emergency department.

So that's kind of been our experience, but I'm curious to hear how it's being used in the outpatient setting?

Dr. Salsitz:
Well as you said, the first fork in the road with somebody who has an alcohol use disorder is what is their goal? Is their goal abstinence, or is their goal reduced heavy drinking? If their goal is abstinence, then disulfiram is an option. But as you mentioned, it's got its own set of problems, it has many more adverse effects than the other two medications, naltrexone and acamprosate, that we've mentioned. And some of them can be severe like hepatitis and neuropathy. But there is a place for it.

And I agree with you, it's nice to get significant others involved and maybe have them monitor the patient, dispense the drug, because the problem with the disulfiram is people stop taking it.

The other interesting point about disulfiram is that it blocks a particular enzyme that metabolizes acid aldehyde. And acid aldehyde is really the culprit in many of the adverse effects of alcohol. And it's interesting that in Asia, about 35% of people have a genetic variation where it's the same as if they were taking disulfiram. They don't have a good enzyme to metabolize the acid aldehyde. And they of course, have low rates of alcohol use disorder because they get the flushing reaction when they take it.

The other important note to know is that you shouldn't start anybody on disulfiram until they've had at least 12 hours of abstinence from alcohol. And after they stop disulfiram, they can still get sick up to 2 weeks later, so they shouldn't drink until that period of time.

So this concludes our brief discussion on some of the agents approved for use an alcohol use disorder. Unfortunately, our time is up. Thanks for listening.

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