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
Indication
4.10. Drugs used in substance dependence
Dosage and
administration
The standard dose is 200mg daily.
Maintenance of abstinence in alcohol dependence
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 gastrointestinal symptoms.
Acamprosate Guidance
Date Prepared: July 2014
Page 1 of 4
Review Date: July 2016
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.
Monitoring
Side Effect
Drowsiness/fatigue
Nausea/vomiting
Halitosis
Sexual dysfunction/lack of libido
Suggested Action
Take at night, usually lessens
Take after food
Ensure dental hygiene
Discuss with doctor, may be another cause
Mood changes
Impaired liver function
Discuss
Need to monitor LFT, may need to discontinue
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.
Interactions
See Appendix A for Disulfiram checklist used in the specialist service.
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
Email
Dr Fleur Ashby, Consultant Psychiatrist
01226 434052
Fleur.Ashby@swyt.nhs.uk
Chris Lawson, Head of Medicines Optimisation,
NHS Barnsley Clinical Commissioning Group
01226 433798
chris.lawson@nhs.net
Sarah Hudson, Lead Pharmacist, SWYPFT
Medicines Information
01226 434649
sarah.hudson@swyt.nhs.uk
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
Acamprosate Guidance
Date Prepared: July 2014
Page 2 of 4
Review Date: July 2016
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.
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.
Acamprosate Guidance
Date Prepared: July 2014
Page 3 of 4
Review Date: July 2016
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.
(6)
Check no contra indications to prescription.
Y
(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
N
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)
Acamprosate Guidance
Date Prepared: July 2014
Page 4 of 4
Review Date: July 2016