Version July 2025
| Initial daily dose | Titration or daily dose range | Select adverse effectsΔ | Contraindications | Dosing and monitoring considerations | |
| Naltrexone (intramuscular) | 380 mg IM every 4 weeks. | — | Injection site reaction: pain, cellulitis, hematoma, induration, sterile abscess. Neurologic: headache, dizziness, sleep disturbance. Gastrointestinal: nausea, decreased appetite, abdominal pain. Hepatic: increased transaminases. | Hypersensitivity to naltrexone or component of formulation. Current opioid use or prescription for pain management. Hepatic failure or elevated liver enzymes ≥3 to 5 times normal. | May begin treatment while patient is still drinking. Liver enzymes should be monitored within several weeks of initiating treatment and then every 6 months during ongoing treatment. |
| Naltrexone (oral) | 50 mg orally once daily. Some individuals may require titration to 100 mg once daily after 1 week. | Usual dose range: 50 to 100 mg/day. | Neurologic: headache, dizziness, sleep disturbance. Gastrointestinal: nausea, decreased appetite, abdominal pain. Hepatic: increased transaminases. | ||
| Acamprosate | 666 mg orally 3 times daily. | — | Gastrointestinal: diarrhea. Neurologic: anxiety, insomnia, depression, dizziness. | Hypersensitivity to acamprosate. CrCl <30 mL/min. | Lower initial dose (ie, 333 mg orally 3 times daily) recommended for individuals with moderate kidney impairment (CrCl 30 to 50 mL/min). Lower initial dose (ie, 333 mg 2 times daily) recommended for individuals weighing <60 kg. |
| Disulfiram | Loading dose: 250 to 500 mg orally once daily for 1 to 2 weeks. | After loading dose, average maintenance dose is 250 mg orally once daily (range: 125 to 500 mg/day). | Neurologic: fatigue, headache, bitter (garlic) taste, neuropathy. Hepatic: hepatitis. | Severe myocardial disease, psychosis, hypersensitivity to thiuram derivatives, ongoing alcohol use. | Liver enzymes should be monitored within several weeks of initiating treatment and then every 6 months during ongoing treatment. |
| Topiramate (immediate release) | 25 mg orally once daily. | Increase daily dose by 25 mg per week for 4 weeks, then increase by 50 mg per week to maximum dose of 300 mg per day as tolerated. Daily doses >50 mg are administered in divided doses.◊ | Gastrointestinal: abdominal pain, diarrhea, nausea. Metabolic: weight loss. Neurologic: dizziness, drowsiness, fatigue, cognitive impairment (eg, memory impairment, word-finding difficulties), paresthesias. | Hypersensitivity to topiramate. | Lower doses (eg, 50% dose reduction) and slower titration recommended for kidney impairment (CrCl <70 mL/min/1.73 m2). |
CrCl: creatinine clearance; IM: intramuscularly.
* Pharmacotherapy is a component of the treatment of alcohol use disorder that is often combined with psychosocial intervention. The decision to use medication is based on the severity of the disorder (ie, our preference is to treat moderate or severe alcohol use disorder with pharmacotherapy plus psychosocial intervention); however, as all treatment decisions are made using shared decision-making, patient preference is the deciding factor. Refer to UpToDate topic for a discussion of choosing treatment modality in those with alcohol use disorder.
¶ This table displays properties and dosing of our preferred first-line pharmacologic agents in the treatment of alcohol use disorder. As minimal direct evidence supports 1 treatment over another, the choice between first-line agents is based on past history, co-occurring disorders, and treatment goal, and the decision is made using shared decision-making. If tolerated, our preference is to treat with the chosen agent for several months (eg, 4 to 6 months) prior to making further decisions. We encourage the individual to try each of the first-line agents if needed as clinically appropriate. For individuals that have not responded to each of the appropriate first-line agents, our preference is a trial of 1 of the second-tier agents (ie, baclofen or gabapentin). Refer to UpToDate topics and an associated algorithm for further discussion of considerations in agents for alcohol use disorder. Changes to pharmacologic management occur simultaneously with psychosocial interventions in all patients agreeable to it.
Δ This is not a complete list. For more information, refer to drug information included within UpToDate.
◊ Refer to topiramate dose-escalation table in UpToDate.
