Choosing initial pharmacotherapy for moderate or severe alcohol use disorder in individuals without opioid use disorder or clinically indicated opioid use^*

CrCl: creatinine clearance.

* This algorithm assumes that treatment for alcohol withdrawal is not necessary or has already been completed. Additionally, this algorithm assumes that the individual does not have a co-occurring opioid use disorder or clinically indicated opioid use. Furthermore, the algorithm assumes that the individual is not pregnant.

¶ We avoid disulfiram in individuals with Child-Pugh Class B or C. Acamprosate is preferred; however, topiramate or naltrexone are acceptable alternatives. Our choice is based on the presence of other co-occurring conditions.

Δ We are cautious when prescribing acamprosate to individuals with kidney dysfunction. We do not treat with acamprosate in individuals with CrCl ≤30. We reduce the dose of acamprosate (eg, 333 mg orally three times daily) for those with moderate kidney function impairment (ie, CrCl of 30 to 50 mL/min). Refer to UpToDate content on the pharmacologic management of alcohol use disorder for further discussion of the use of acamprosate.

◊ We are cautious in prescribing topiramate to individuals with cognitive dysfunction as topiramate has been associated with cognitive impairment.

§ While abstinence remains the primary goal of treatment for individuals with alcohol use disorder, reduction of heavy drinking may be acceptable for patients who lack readiness to quit.

¥ We are cautious in prescribing disulfiram to individuals with a cognitive disorder who may have difficulty understanding the effects of alcohol combined with disulfiram.