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May 21, 2014
Analysis Determines Best Drug Treatments for
Alcohol-Use Disorders Chapel Hill, NC—What are the most effective drug therapies for decreasing alcohol consumption? Answering that question was the goal of an analysis of more than 120 studies led by researchers from the University of North Carolina at Chapel Hill. The results were published recently in the Journal of the American Medical Association. Background in the study notes that less than 10% of patients with alcohol-use disorders (AUDs) are treated with medications to help them reduce consumption, yet AUDs are known to increase illness and early death threefold. Overall, the analysis finds that acamprosate and oral naltrexone show the strongest evidence for decreasing alcohol consumption. Researchers identified 122 randomized clinical trials (RCTs) and one cohort study—involving 22,803 participants in total—that met criteria for inclusion in the analysis. Most of those studies evaluated acamprosate (27 with 7,519 participants), naltrexone (53 with 9,140 participants), or both. Results are presented as a number needed to treat (NNT), which is the average number of patients who need to be treated to see benefit in one patient. The researchers report that the NNT to prevent return to any drinking for acamprosate was 12, compared to 20 for 50 mg of oral naltrexone. The NNT to prevent return to heavy drinking was 12 for the same dosage of oral naltrexone, however. Injectable naltrexone was only found to be associated with reduction in heavy drinking days. The report says that head-to-head trials have not established superiority of either medication. The report points out that many clinicians may be more familiar with disulfiram, which has been in use since the 1950s, than naltrexone or acamprosate. Evidence from well-controlled trials, however, does not adequately support an association between disulfiram and preventing return to any drinking or improvement in other alcohol consumption outcomes, according to the authors. In terms of off-label prescribing, moderate evidence was found for improvement in some consumption outcomes for nalmefene and topiramate. “When clinicians decide to use one of the medications, a number of factors may help with choosing which medication to prescribe, including the medication's efficacy, administration frequency, cost, adverse events, and availability,” the authors conclude. An accompanying editorial says the analysis provides valuable information that medical professionals can use to consult with patients on the best therapies for AUDs. “Treatment of AUD is considered an essential health benefit under health care reform. More patients with AUDs will have insurance, which could increase their access to evidence-based treatments for AUDs. The article by Jonas and colleagues should encourage patients and their clinicians to engage in shared decision making about AUD treatment options,” write Katharine A. Bradley, MD, MPH, of the Group Health Research Institute in Seattle, and Daniel R. Kivlahan, PhD, of the Veterans Health Administration in Washington, DC. “By identifying four effective medications for AUD [naltrexone, acamprosate, topiramate, and nalmefene], the authors highlight treatment options for a common medical condition for which patient-centered care is not currently the norm. Patients with AUDs should be offered options, including medications, evidence-based behavioral treatments, and mutual support for recovery. Moreover, patients should expect shared decision making about the best options for them,” Bradley and Kivlahan add.
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