Naltrexone and Alcohol Consumption Guidelines

Introduction to Naltrexone

The American Association for the Study of Liver Diseases recommends that patients on naltrexone should avoid alcohol consumption, as continued alcohol use while on naltrexone can lead to disease progression in those with alcohol-induced liver disease and may reduce the medication's effectiveness in treating alcohol dependence 1, 2
Naltrexone is a pure opioid antagonist approved in 1995 for the treatment of alcoholism that works by controlling cravings for alcohol 1

Naltrexone decreases dopamine concentration in the brain and dampens activation of the reward pathway by alcohol, thereby decreasing excessive drinking and recurrence rates 3
The American College of Physicians notes that naltrexone has been shown to lower the risk of relapse in short-term treatment according to systematic reviews 1

The National Institute of Diabetes and Digestive and Kidney Diseases indicates that naltrexone has been shown to cause hepatocellular injury, particularly at higher doses 1
The American Academy of Family Physicians recommends that liver function tests should be monitored at baseline and every three to six months during treatment 4
Naltrexone is not recommended in patients with alcoholic liver disease (ALD) due to the risk of toxic liver injury 3

For patients with evidence of alcohol-induced liver disease, strict abstinence must be recommended as continued alcohol use is associated with disease progression 1, 2, 5
The American Association for the Study of Liver Diseases suggests that baclofen may be a better alternative for patients with liver cirrhosis who need medication to maintain abstinence 3, 6
Acamprosate may be considered as an alternative to naltrexone, particularly for patients with liver concerns, as it helps reduce withdrawal symptoms and maintain abstinence 1, 2
Combination therapy with counseling is recommended to maximize effectiveness in maintaining abstinence 1, 2, 5

For patients with alcohol dependence without liver disease, naltrexone (50 mg daily) combined with counseling can be effective in reducing alcohol consumption 5
For patients with any degree of alcoholic liver disease, strict abstinence should be recommended and naltrexone should be avoided due to hepatotoxicity risk 3

There is no safe amount of alcohol consumption that can be recommended after an episode of alcoholic hepatitis, as it can persist or redevelop 2
Patients who attempt to cut back but not stop drinking altogether have a significant risk of recidivism 2
Naltrexone cannot be used in patients requiring opioids for pain control, as it will block pain relief from opioid agonists 4

Nausea is the most frequently reported side effect, occurring commonly enough to warrant dose reduction strategies 7, 8
Constipation affects a significant proportion of patients on naltrexone therapy 7, 8
Insomnia and sleep disturbances occur frequently 7, 8
Dry mouth (xerostomia) is a persistent complaint 7, 9

Liver function tests should be obtained at baseline and monitored every 3-6 months during treatment 10

Bupropion (in the combination naltrexone/bupropion) carries a black box warning for increased suicidal thoughts in young adults under 24 years 7, 9

Naltrexone/bupropion combination can cause elevated heart rate and blood pressure 9, 11
The medication should be avoided in patients with uncontrolled hypertension 7, 11

Concurrent use with monoamine oxidase inhibitors (for naltrexone/bupropion) is contraindicated 7, 11

All weight loss medications, including naltrexone, are contraindicated in women who are pregnant or actively trying to conceive 9
Women of reproductive potential must use reliable contraception 9