Personalised Pharmacotherapy: Selecting Medications for Individual Patients

Available evidence does not enable clear recommendations as to which front-line medication is best suited to different patients. The majority of studies that have examined predictors of treatment response have been retrospective analyses. Several studies indicate that naltrexone may be particularly efficacious among those that drink alcohol for the rewarding effect of alcohol. Other studies have reported naltrexone should be considered for patients who want to reduce heavy drinking whereas acamprosate is better for those who seek abstinence. However, it is important to note that neither benefit is large or consistent enough to direct a clinical recommendation as yet, particularly given that the majority of acamprosate trials did not include heavy drinking measures as an outcome. Similarly, while there have been several retrospective studies reporting genetic moderators of treatment response (eg µ-Opioid receptor (OPRM1) genotype for naltrexone), no prospective study has confirmed any genetic predictors to date.  

Thus, there is still little scientific consensus with which to direct a personalised approach with confidence. Clinical decision making can nonetheless be guided by several factors (depicted in Table 1). These include i) individual patient factors: such as side effects, prior experience, treatment goals, capacity to adhere to treatment regime, concomitant physical conditions and mental disorders and ii) resource factors: social supports and the cost of some medications will be prohibitive for some patients. Precautions for the main physical conditions are listed in Table 1. Most front-line medications appear to be safe in the context of concurrent mental disorders although caution may be applied regarding disulfiram and psychosis. Details on management approaches for AUD and comorbid physical disorders can be found in Chapter 22 and comorbid mental disorders can be found in Chapter 21.