Medication Reference Card: Alcohol Use Disorder

Disulfiram (Antabuse)

200–500 mg/day orally · Requires alcohol-free ≥24 h before initiation · Not PBS-listed (full cost to patient)

Dr Basanth Kenchaiah
FRANZCP · Cert. Addiction Psych. · MBBS · DPM · DNB (Psychiatry) Addiction Psychiatrist v1.2 · October 2026

Audience Clinicians

Purpose Prescribing quick-reference for disulfiram (Antabuse) in alcohol use disorder (AUD).

Key messages

Aldehyde dehydrogenase inhibitor: causes aversive flushing/nausea/tachycardia if alcohol is consumed
200 mg/day standard dose; supervised administration strongly preferred to ensure adherence and safety
Contraindicated in severe cardiac or hepatic disease, psychosis, and concurrent metronidazole or isoniazid

For Patients

Disulfiram works by causing an unpleasant physical reaction (flushing, nausea, and palpitations) if alcohol is consumed. This creates a strong deterrent. It works best when taken under supervision and when a person is highly motivated to stop drinking.

Particularly useful when comorbid with:

Cocaine use disorder (dopamine-beta-hydroxylase inhibition) Supervised administration available (partner / pharmacist / GP) Short-term commitment to abstinence (professional / legal obligations) Deterrence-based motivation profile

For Clinicians

Mechanism

Inhibits aldehyde dehydrogenase, causing toxic accumulation of acetaldehyde after alcohol ingestion → flushing, tachycardia, nausea, vomiting, hypotension (disulfiram-ethanol reaction / DER). Also inhibits dopamine beta-hydroxylase: basis for cocaine use disorder effect.

Dosing

Maintenance: 200 mg/day orally (range 200–500 mg/day). Patient must be alcohol-free for at least 24 hours before initiation. DER risk persists up to 14 days after last dose. Counsel patients clearly. Supervised dosing (partner, pharmacist, GP) significantly improves efficacy.

Evidence

Fuller et al. (JAMA 1986; blinded RCT, 605 men): no significant difference in total abstinence or time to first drink; among men who drank, those on 250 mg reported fewer drinking days. Meta-analysis (Skinner et al. PLoS One 2014; 22 RCTs, 2,414 participants; not a Cochrane review): disulfiram outperformed controls, but only in open-label trials (blinded trials showed no efficacy); within open-label trials it was superior when administration was supervised and not significantly better when unsupervised, and it outperformed naltrexone and acamprosate (the acamprosate comparison rests on three studies, with wide uncertainty). Limitations: 89% male participants and high heterogeneity.

Cautions

Contraindicated: severe cardiac disease, psychosis, significant impulsivity, pregnancy
Avoid with metronidazole (psychotic reaction), paraldehyde, amitriptyline
Hepatotoxicity risk: baseline LFTs, repeat at 2 weeks; avoid if ALT/AST >3× ULN
Drug interactions: warfarin (↑INR, monitor closely), phenytoin (↑levels)
DER can be severe: ensure patient understands hidden alcohol in medications, foods, mouthwash