Tyler Vanderhoof, MD PGY-4 Psychiatry Resident Department of Psychiatry and Behavioral Sciences Emory University Atlanta, Georgia
John J. Reitz, MD PGY-4 Psychiatry Resident Department of Psychiatry and Behavioral Sciences Emory University Atlanta, Georgia
Yi-lang Tang, MD, PhD Associate Professor Department of Psychiatry and Behavioral Sciences Emory University Atlanta, Georgia Addiction Psychiatrist Substance Abuse Treatment Program Atlanta Veteran Health Care System Decatur, Georgia
Disclosures The authors report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
Topiramate blocks voltage-gated sodium channels and enhances GABA-A receptor activity.9 It is indicated for the treatment of seizures, migraine prophylaxis, weight management, and weight loss. Several clinical trials, including RCTs,10-12 demonstrated that topiramate was superior to placebo in reducing the percentage of heavy drinking days and overall drinking days. Some also showed that topiramate was associated with abstinence and reduced craving levels.12,13 A meta-analysis by Blodgett et al14 found that compared to placebo, topiramate lowered the rate of heavy drinking and increased abstinence.
Topiramate is dosed from 50 to 150 mg twice daily, although some studies suggest a lower dose (≤75 mg/d) may be associated with clinical benefits.15,16 One important clinical consideration: topiramate must follow a slow titration schedule (4 to 6 weeks) to increase tolerability and avoid adverse effects. Common adverse effects include sedation, word-finding difficulty, paresthesia, increased risk for renal calculi, dizziness, anorexia, and alterations in taste.
Baclofenis a GABA-B agonist FDA-approved for the treatment of muscle spasticity related to multiple sclerosis and reversible spasticity related to spinal cord lesions and multiple sclerosis. Of note, it is approved for treatment of AUD in Europe.
In a meta-analysis of 13 RCTs, Pierce et al17 found a greater likelihood of abstinence and greater time to first lapse of drinking with baclofen compared to placebo. Interestingly, a subgroup analysis found that the positive effects were limited to trials that used 30 to 60 mg/d of baclofen, and not evident in those that used higher doses. Additionally, there was no difference between baclofen and placebo with regard to several important outcomes, including alcohol cravings, anxiety, depression, or number of total abstinent days. A review by Andrade18 proposed that individualized treatment with high-dose baclofen (30 to 300 mg/d) may be a useful second-line approach in heavy drinkers who wish to reduce their alcohol intake.
