1- What are the most important things to know before starting naltrexone?
Naltrexone/Vivitrol discussed in the Opioid videos slightly differently. Feel free to refer to that video as well. Most common GI system side effects (Nausea, abdominal pain, etc), CNS, Central nervous system (Feeling tired, restless, insomnia). There is a black box warning regarding possible liver injury so most prescribers may request getting baseline liver function labs. The data regarding liver toxicity, however, may be less than once thought. Before taking this medication one must be abstinent from any opioids for about a week or more otherwise it may lead to terrible side effects from precipitated withdrawal. In my experience, this medication is well tolerated and people endorse it helps with cravings.
2-What are the most important things to know before starting acamprosate (Campral)?
This drug is pretty well tolerated. There is no black box warning, but if you have severe renal (kidney) disease or are pregnant you should not be on it. The most common side effect to worry about is mild diarrhea. The medication has no drug-drug interactions.
3-What are the most important things to know before starting Disulfate (Antabuse)?
This drug is meant to purposely cause a bad reaction if taken with alcohol. This reaction is thought to be able to prevent patients from drinking alcohol. Because of the purposeful bad reaction, It can be dangerous and because it may be dangerous, your clinician may not prescribe it.
There is a Black Box stating, “Never administer to a patient in a state of alcohol intoxication or without the patient’s full knowledge” This mix can be fatal but it’s what the medication was meant to do. In summary, taking this medication should be taken seriously. In fact, one of the contraindications for prescribers to prescribe this medication to someone is if the patient has a history of being impulsive, along with psychosis, significant liver disease, esophageal varices, and pregnancy should not be on this medication. This drug may cause some liver toxicity and should be used with caution with patients with Coronary Artery disease.
Furthermore, it has many drug interactions. The more common side effects include skin rashes, drowsiness, headache, metallic taste, decreased libido/potency
I don’t have too much experience with this medication, but I have heard of carefully selected patients doing well on this.
4-What are the most important things to know before starting Topiramate (Topamax)?
The other three medications I mentioned are FDA approved. But I have had some success with Topiramate. This can be considered an antiepileptic drug so it is a strong medication. Although there is no black box warning, In 2008, the FDA considered a black box warning for antiepileptic drugs because of increased Suicidal ideations. They never placed a black box warning, however, since they deemed it not to be too common. Side effects of this medication include cognitive impairment (e.g. foggy thinking), weight loss, sudden blurry vision/eye problems, and metabolic acidosis. In my experience, topiramate is pretty well tolerated.
5- Which one do you choose?
I don’t have a strong opinion on which medication is best. I typically prescribe Naltrexone as a first medication. Some clinicians may state that if the patient drinks impulsively (for the feeling good just to feel good) naltrexone may be the best option while if the patient drinks compulsively (drinking to get rid of bad feelings) Acamprosate may be the best option. I, however, do not have a huge preference for one over the other. I, however, worry to give disulfiram due to the side effects. As mentioned, I think topiramate may help in conjunction.