Acamprosate Versus Naltrexone in Alcohol Use Disorder

Alcohol use disorder can be managed with medications. American Psychiatric Association Guidelines recommend acamprosate or naltrexone as a first-line agent for moderate to severe management of alcohol use disorder. In this article, I will compare acamprosate versus naltrexone and highlight some of the most important differences. This comparison of acamprosate versus naltrexone would definitely be a good thing to know when preparing for a board exam!

Liver or Renal Impairment Matters

Naltrexone’s risk of causing hepatic impairment means that it should not be used in patients who have preexisting liver disease. Acamprosate is primarily excreted in the urine. In patients with renal impairment (i.e. CrCl <30 ml/min), acamprosate should be avoided as this medication will accumulate. A reduced dose of acamprosate should be used in patients with a CrCL in the 30-50 mls/min range.

ADRs – Acamprosate Versus Naltrexone

Acamprosate is well known to cause diarrhea. This is one of the most prominent adverse effects of this medication and should be taken into consideration if you have a patient who already struggles with this issue (i.e. IBS with diarrhea, Crohn’s, etc.). The other major distinction is that naltrexone is more likely to increase hepatic enzymes compared to acamprosate. Central nervous system changes can happen with both agents. If the injectable formulation of naltrexone is used, this can obviously result in some injection site reactions compared to oral naltrexone and acamprosate.

Contraindications

In addition to recognizing if a patient has liver concerns, opioid use may also steer therapy selection toward acamprosate. Recall that naltrexone is an opioid antagonist and this medication should be avoided in alcohol use disorder if these patients are taking opioids.

Dosing

The frequency of dosing may be a problem for some patients taking acamprosate. Oral naltrexone only has to be dosed once daily while the recommended dosing for acamprosate is three times daily. Injectable naltrexone provides an option for those who have a hard time remembering to take oral medications. The injection is typically given every 4 weeks.

This article gives a quick summary of acamprosate versus naltrexone in alcohol use disorder and why you might use one versus the other.

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