II. Background

  1. Used since 1951

III. Mechanism

  1. Buildup of acetaldehyde if drinks on Disulfiram, with secondary severe reaction
  2. Taking Antabuse seals daily sobriety contract
    1. Today they will not drink
  3. Does not reduce Alcohol craving

IV. Efficacy

  1. No better than Placebo in most studies
  2. May have better efficacy when administered under close supervision

V. Contraindications

  1. Concurrent use of medications with drug interaction
    1. Metronidazole (Flagyl)
    2. Medication containing Alcohol (e.g. some Inhalers)
  2. Age over 60 years
  3. Comorbid illness
    1. Cirrhosis with Portal Hypertension
    2. Coronary Artery Disease
    3. Chronic Renal Failure
    4. Diabetes Mellitus
    5. Peripheral Neuropathy
    6. Seizure disorder
    7. Severe respiratory disease
  4. Prior Psychosis on Antabuse

VI. Drug Interactions

  1. See contraindications above for other interactions
  2. Medications that raise Antabuse levels
    1. SSRI
    2. Tricyclic Antidepressants
    3. Dilantin
    4. Coumadin
    5. Isoniazid
    6. Unsteady gait

VII. Adverse Effects: Symptoms and Signs of Antabuse with Alcohol reaction

  1. Headache
  2. Nausea and Vomiting
  3. Large red hot pruritic rash
  4. Shortness of Breath
  5. Cardiac Arrest
  6. Seizure
  7. Coma
  8. Death

VIII. Adverse Effects: Antabuse alone

  1. Fatigue (resolves after 2-3 weeks)
  2. Garlic breath
  3. Metallic Taste
  4. Acne (Treat with non-Alcohol based Comedolytic)
  5. Rare neurologic sequelae
  6. Rare hepatotoxicity
  7. Peripheral Neuropathy (or neuritis)

IX. Management: Alcohol-Antabuse reaction

  1. Benadryl 50 mg IM
    1. Give additional Benadryl for home

X. Labs (consider, done by some clinicians)

  1. Liver Function Tests
    1. Baseline, 2 weeks, 3 months and then every 6 months

XI. Dose

  1. Antabuse 250 mg orally daily (may be increased up to 500 mg daily)
  2. Do not start for at least 12 hours from last Alcohol intake

XII. Precautions

  1. Counsel: life threatening risk Alcohol and Antabuse
  2. If choosing to drink, wait 14 days after last Antabuse
  3. Alcohol-Antabuse reactions occur at low Alcohol levels
  4. Do not use Flagyl with Antabuse
  5. Read Labels: Alcohol is in many products!
    1. Flavoring in frosting
    2. Sauces
    3. Wine Vinegar (14% Alcohol)
    4. Aerosol propellant (Hair spray)
    5. Skin absorption
      1. Alcohol swab on lab draw
      2. Hand lotion
      3. Soap
    6. Gel toothpaste
    7. Mouthwash
    8. Cough lozenge, Cough medications
    9. Nyquil (35% Alcohol)
  6. Every patient must have a medic alert card
    1. Alerts that patient is in on Antabuse
    2. Do not give Alcohol, paraldehyde or related product
  7. Every patient should sign a witnessed consent
  8. Patient Education handouts are highly recommended
  9. Document that the above has been reviewed with patient

XIII. Safety

  1. Pregnancy Category C
  2. Lactation: Unknown

XIV. Cost

  1. Cost: $190/month trade name (but generic available for $50 per month)

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Cost: Medications

disulfiram (on 5/17/2017 at Medicaid.Gov Survey of pharmacy drug pricing)
DISULFIRAM 250 MG TABLET Generic $1.54 each
DISULFIRAM 500 MG TABLET Generic $2.95 each

Ontology: Disulfiram (C0012772)

Definition (NCI_NCI-GLOSS) A drug that slows the metabolism of retinoids, allowing them to act over a longer period of time.
Definition (NCI) A carbamoyl derivate used in the treatment of alcoholism. Disulfiram irreversibly inhibits acetaldehyde dehydrogenase that oxidizes the ethanol metabolite acetaldehyde into acetic acid. This leads to an accumulation of acetaldehyde that produces a variety of very unpleasant symptoms referred to as the disulfiram-alcohol reaction. This reaction includes , but is not limited to, flushing, headache, respiratory difficulty, nausea,vomiting, sweating, thirst, chest pain, tachycardia, blurred vision and hypotension.
Definition (MSH) A carbamate derivative used as an alcohol deterrent. It is a relatively nontoxic substance when administered alone, but markedly alters the intermediary metabolism of alcohol. When alcohol is ingested after administration of disulfiram, blood acetaldehyde concentrations are increased, followed by flushing, systemic vasodilation, respiratory difficulties, nausea, hypotension, and other symptoms (acetaldehyde syndrome). It acts by inhibiting aldehyde dehydrogenase.
Definition (CSP) carbamate derivative used as an alcohol deterrent; it is a relatively nontoxic substance when administered alone, but markedly alters the intermediary metabolism of alcohol; when alcohol is ingested after administration of disulfiram, blood acetaldehyde concentrations are increased, followed by flushing, systemic vasodilation, respiratory difficulties, nausea, hypotension, and other symptoms (acetaldehyde syndrome); it acts by inhibiting aldehyde dehydrogenase.
Definition (PDQ) A carbamoyl derivate used in the treatment of alcoholism. Disulfiram irreversibly inhibits acetaldehyde dehydrogenase that oxidizes the ethanol metabolite acetaldehyde into acetic acid. This leads to an accumulation of acetaldehyde that produces a variety of very unpleasant symptoms referred to as the disulfiram-alcohol reaction. This reaction includes , but is not limited to, flushing, headache, respiratory difficulty, nausea,vomiting, sweating, thirst, chest pain, tachycardia, blurred vision and hypotension. Check for "http://www.cancer.gov/Search/ClinicalTrialsLink.aspx?id=42291&idtype=1" active clinical trials or "http://www.cancer.gov/Search/ClinicalTrialsLink.aspx?id=42291&idtype=1&closed=1" closed clinical trials using this agent. ("http://nciterms.nci.nih.gov:80/NCIBrowser/ConceptReport.jsp?dictionary=NCI_Thesaurus&code=C447" NCI Thesaurus)
Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH D004221
SnomedCT 39516004, 387212009, 256160001, 411488001
LNC LP16119-7, MTHU006972
English Bis(diethylthiocarbamoyl) Disulfide, Disulfide, Tetraethylthiuram, Tetraethylthiuram Disulfide, disulfiram, Thioperoxydicarbonic diamide (((H2N)C(S))2S2), tetraethyl-, TTD, Tetraethylthioperoxydicarbonic Diamide, Teturamin, DS, Tetraethylthioperoxydicarbonic Diamide, ((H2N)C(S))2S2, Disulphiram product, Disulphiram, disulfiram (medication), DISULFIRAM, Disulfiram [Chemical/Ingredient], disulphiram, tetraethylthiuram disulfide, Tetraethylthiuram disulfide (substance), Tetraethylthiuram disulfide (product), Tetraethylthiuram disulfide, Tetraethylthiuram disulphide, Disulfiram product, Disulfiram (product), Disulfiram (substance), Disulfiram
Swedish Disulfiram
Czech disulfiram
Finnish Disulfiraami
Russian ANTABUS, ETILDITIURAM, TETURAM, DISUL'FIRAM, TETRAETILTIURAMDISUL'FID, АНТАБУС, ДИСУЛЬФИРАМ, ТЕТРАЭТИЛТИУРАМДИСУЛЬФИД, ТЕТУРАМ, ЭТИЛДИТИУРАМ
Japanese ジスルフィラム, テトラエチルチウラムジスルフィド
French Disulfiram, Disulfirame
Italian Disulfuro tetraetiltiuramo, Disulfiram
Croatian DISULFIRAM
Polish Antabus, Disulfiram, Anicol
Spanish disulfuro de tetraetiltiuram (producto), disulfuro de tetraetiltiuram, disulfuro de tetraetiltiuram (sustancia), disulfiram (producto), disulfiram (sustancia), disulfiram, tetraetiltiuram disulfuro, Disulfiram, Disulfuro de Tetraetiltiuramo
Portuguese Tetraetiltiuramo Dissulfeto, Dissulfeto de Tetraetiltiuramo, Dissulfiram
German Disulfiram, Tetraethylthiuramdisulfid

Ontology: Antabuse (C0591096)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH D004221
French Antabuse
English antabuse, Antabuse, Allphar Brand of Disulfiram, Odyssey Brand of Disulfiram, Orphan Brand of Disulfiram