Q 1. Can disulfiram be given surreptitiously (without the consent of the patient)?
Ans. Disulfiram cannot be given without the consent of the patient. It is necessary to educate the patient regarding the side effects of Disulfiram as well as the nature of 'Disulfiram Ethanol Reaction' (DER) before initiation of Disulfiram.
Q 2. Do deaths occur with Disulfiram?
Ans. Deaths with Disulfiram are very rare. The reported deaths in the literature are one in lakh users of disulfiram. Experience at our centre shows that disulfiram can be safely used in patients without fear of causing deaths.
Q 3. Should one stop Disulfiram during other common illness such as fever, diarrhea because of the fear of interaction with other commonly prescribed medicines?
Ans. No. One can safely continue Disulfiram during common illness without fear of interaction with commonly prescribed medications.
Q 4. The patient is having weakness after the start of Disulfiram and requests to stop Disulfiram. Should I stop it?
Ans. On most of the occasion, weakness is as a result of chronic effects of alcohol ingestion and NOT because of Disulfiram per se. One must check the patient's motivation if he is requesting to stop Disulfiram and conduct motivational enhancement therapy. Also LFT reports should be monitored.
Q 5. Since the effect of disulfiram lasts for 10 - 14 days, should I ask the patient to ingest Disulfiram once every 10 days?
Ans. Though the effect of Disulfiram lasts for 10 - 14 days, Disulfiram should be taken every day to maintain constant and adequate blood levels.
Q 6. The patient claims that he is addicted to whiskey only. He asks whether he can consume beer or wine. What should I do?
Ans. No alcohol containing beverages should be consumed when the patient is on disulfiram. For further details see the paragraph on Beverages to be avoided during Disulfiram therapy.
Q 7. The patient has been taking Disulfiram since 9 months. Would he continue to remain free of alcohol lifelong as a result of this therapy?
Ans. Disulfiram prolongs the duration of abstinence in an alcohol dependent individual. There is always a risk of relapse at a future date. The risk of relapse reduces with increase in duration of abstinence.
Q 8. What is the optimum dose of disulfiram in an individual patient?
Ans. Disulfiram should be started as a single tablet containing 250 mg, once a day. It may take at least 4 - 5 days to reach a steady state level. During follow up, if it is found that the patient is using alcohol while regularly compliant on disulfiram, then it is necessary to carry out a disulfiram ethanol reaction and increase the dosage to 500 mg OD if no reaction occurs.
Q 9. Can disulfiram be administered to a patient who is in a state of alcohol intoxication or without their full knowledge?
Ans. Disulfiram should never be administered to a patient who is in a state of alcohol intoxication or without their full knowledge. Under both the circumstances, patient will develop disulfiram-ethanol reaction (DER) which can be life threatening.
Q 10. What is disulfiram-ethanol reaction (DER)?
Ans. Disulfiram acts by binding irreversibly to the enzyme acetaldehyde dehydrogenase, (ALDH) leading to inactivation of the enzyme. When alcohol is consumed subsequent to disulfiram intake, there is an accumulation of acetaldehyde due to inhibition of the enzyme that metabolises it. Elevated levels of acetaldehyde are responsible for the unpleasant effects experienced. This is termed as the Disulfiram- Ethanol Reaction (DER). High levels of acetaldehyde produce nausea, substantial vomiting, hyperventilation, chest pain, flushing, throbbing headache, light-headedness, palpitation, blurred vision and other unpleasant symptoms. In rare cases arrhythmias, acute heart failure, convulsion and
death may occur. The patient's reaction will be proportional to the dosage of both disulfiram and alcohol, and will continue to occur as long as alcohol is being metabolized.
Q 11. How should disulfiram-ethanol reaction (DER) be treated?
Ans. The disulfiram-ethanol reaction is treated symptomatically. Patient will require monitoring of pulse and blood pressure. Vasopressors and antiarrythymic agents may have to be given in case hypotension or cardiac arrhythmias occur.
Q 12. How does disulfiram help in maintaining abstinence or preventing relapse?
Ans. The underlying principle for using disulfiram in treating alcoholism is that most alcoholics taking disulfiram will avoid drinking because they fear getting sick. Thus, disulfiram prevents impulsive drinking and allows the patient time to think about other ways to cope with acute cravings or stressful moments.
Q 13. When to start disulfiram in a patient using alcohol ?
Ans. Disulfiram should be started after detoxification from alcohol is completed and the patient is free of alcohol or alcohol containing beverages for at least 12 hours before the start of disulfiram.
Q 14. At which time of the day, disulfiram should be used daily?
Ans. The timing of the dose should be fixed, such that the patient takes the tablet at a particular time of the day.Some patients may experience sedation with morning use; in such cases the dose may be shifted to night time. It is always advisable to take the tablets in the morning following the breakfast under the supervision of a significant family member. This helps in two ways; Firstly, it takes away from the patient the thought of using alcohol for the whole day and secondly it helps in building the trust between the
patient and the significant family member.
Q 15. What should be done if a patient develops psychosis while on disulfiram?
Ans. Psychotic reactions are uncommon with disulfiram. However, it is usually noted when a patient is on disulfiram due to the following reasons: high dosage of disulfiram, combined toxicity (with metronidazole or isoniazid), or as a rare side-effect in some individual vulnerable for such reactions. Identification of the cause along with appropriate measures is required to be taken. To be on the safer side, it is always advisable to stop disulfiram first. If needed, anti-psychotic medications can be used for short-term basis as judged clinically.
Q 16. What is the optimum duration of therapy with disulfiram?
Ans. The optimal duration of disulfiram treatment is not known. The optimal duration of therapy varies with the individual patient and the agreed treatment goals. The patient will remain abstinent as long as he is compliant on disulfiram. It is advisable to give more emphasis on the agreed treatment goals of disulfiram treatment rather than setting an arbitrary duration of treatment.
Q 17. What should be the usual duration of treatment with disulfiram?
Ans. Usually disulfiram therapy should be continued for a period of 6 to 9 months till the time the patient feels confident to abstain from alcohol without medication, the risk for relapse has been reduced and patient is rehabilitated. However, in some patients, the therapy would have to continue for a longer period of time. Patients neither develop tolerance to disulfiram nor to the disulfiram ethanol reaction. During this time, the patient is expected to be able to master the coping strategies necessary to deal with difficult situations without resorting to alcohol.
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