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  » Alcoholism and treatment  »  Disulfiram
(Tetraethyl thiuram disulphide. Antabuse, 200 mg tablets.): Ensure that alcohol has not been consumed for at least 12 hours before initiating therapy. Treatment is initiated with 800 mg as a single dose on the first day. The single daily dose is gradually reduced over 5 days to a maintenance dose of 100-200 mg daily; treatment may be continued for up to 1 year. After a week's therapy, if a small amount of alcohol is given to the patient it produces toxic reactions, such as flushing, perspiration, palpitation, marked nausea, vomiting, fall of blood pressure and even collapse. The patient thus realizes that while in this drug he cannot tolerate even small doses of alcohol and would abstain from drinking. Severe reactions can occur even with the first dose and hence, this treatment should be carried out in a hospital. Many cases in which disulfiram has produced violent reactions following alcohol ingestion resulting in death have been reported.

Mechanism of action: The drug interferes with the oxidation of acetaldehyde formed during the metabolism of alcohol. This raises the blood level of acetaldehyde which acts directly on the cardiovascular system. In addition, disulfiram also inhibits dopamine beta oxidase and thus interferes with the synthesis of noradrenaline. This causes depletion of catecholamines.
The drug is slowly and incompletely absorbed from the gut and is metabolized slowly.

Adverse reactions: The drug can cause drowsiness, nausea, headache, cramps, fatiguability and a metallic taste in the mouth. Confusional state is rare. Severe acetaldehyde reaction is described earlier.
Disulfiram inhibits metabolic degradation of warfarin, theophylline, benzodiazepines, tricyclic antidepressants and phenytoin. The first and the last interactions can be hazardous.

Contraindications of disulfiram:
   - Hepatic and circulatory diseases.
   - Uncontrolled diabetes mellitus.
   - In alcoholics with obvious personality changes.
General anaesthetics or paraldehyde, which produce similar effects as alcohol, should not be administered simultaneously with disulfiram. Occasionally, this can cause sever reactions such as marked fall in blood pressure and collapse.

Carbimide, a drug with similar properties, has a shorter duration of action.

Institutional therapy: Psychotherapy and drug therapy can be supported by institutional therapy (Alcoholics Anonymous, AA) where the patient can see for himself the ex-alcoholics who have become abstainers and are living a happy life. This can help to boost the patient's morale. A religious and spiritual approach is also useful.
In very chronic cases certain abnormalities of personality develop and the treatment becomes far more difficult. Thus, in Korsakoff's psychosis there is a marked impairment of memory, disorientation in space, impaired physical capacity and diminution of willpower. The result of aversion therapy with drugs are generally disappointing.

Table 4.3 describes the symptomatic treatment of alcohol withdrawal syndromes.

Table 4.3: Symptomatic treatment of alcohol withdrawal syndromes

- Maintenance of nutrition and electrolyte balance.
- IV glucose for hypoglycemia.
- IV thiamine (100 mg).
- Prevent injuries.
- Clonidine (orally) 0.1 mg to 0.4 mg qid, or atenolol (orally) 50-100 mg daily, to combat autonomic hyperactivity.
- Sedatives such as diazepam or chlordiazepoxide.
- Diazepam IV to treat convulsions.
- Do not use phenothiazines, as they can precipitate convulsions.