Peripheral Neuropathy due to Disulfiram

The Positive and Negative Outcome of Morphine and Disulfiram Subacute Co-Administration in Rats in the Absence of Ethanol Challenge

Recently, a well-known anti-alcohol agent, disulfiram (DSF), has gain much interest, as it was found to be effective in the treatment of cocaine abusers, thus also giving hope for patients addicted to opioids and other illicit drugs. Therefore, this study was aimed to investigate the possible outcome that might occur within the subacute co-administration of both morphine (MRF) and DSF in rats, but in the absence of ethanol challenge. As observed, intraperitoneal DSF dose-dependently enhanced MRF-mediated analgesia with the maximal efficacy at a dose of 100 mg/kg. Furthermore, MRF-induced tolerance and aggressive behavior were significantly reduced by DSF (100 mg/kg, i.p.) in comparison to MRF solely. Nonetheless, significant blood biochemical markers of hepatotoxicity were found (i.e., alteration in the levels of glutathione, blood urea nitrogen, etc.), following a combination of both drugs. Likewise, histological analysis of liver tissue revealed severe changes in the group of DSF + MRF, which includes swelling, cell death, damage to certain vessels, and hemorrhages into the liver parenchyma. Our findings indicate that DSF should be used with extreme caution, especially within the course of subacute concomitant use with MRF, as several possible side effects may take place.

Disulfiram-induced neuropathy: a case report

Disulfiram is widely used for aversive treatment of alcoholism. Neuropathy is one of the most severe side effects of disulfiram therapy. We report the case of a young man who developed a neuropathy following disulfiram administration, with a virtually complete recovery within 2 months.

Clinical description of toxic neuropathies

Toxic neuropathy, although rare, is an important consideration in the setting of a known or suspected toxic exposure in the workplace or other environment. This chapter discusses the clinical and electrodiagnostic evaluation of peripheral neuropathies, highlighting findings that direct further workup and may point to specific toxins as etiology. The difficulty of establishing causality of a toxin in relation to peripheral neuropathy is discussed; guidelines for establishing causality are presented. Examples of common industrial toxins are listed, including their typical industrial uses and their mechanisms of action in producing neuropathy. Characteristic clinical presentations of specific toxic neuropathies are highlighted with selected case studies.

Disulfiram-induced transient optic and peripheral neuropathy: a case report

AIM

To report a case of optic and peripheral neuropathy after chronic use of disulfiram for alcohol dependence management.

MATERIALS AND METHODS

A case report.

RESULTS

A 57-year-old male presented with gradual loss of vision in both eyes with intermittent headaches for 2 months. He also complained of paraesthesia with numbness in both feet. His vision was 6/15 and 2/60 in the right and left eyes, respectively. Fundoscopy revealed bilaterally swollen optic nerve heads. Visual field testing confirmed bilateral central-caecal scotomata. He had been taking disulfiram for alcohol dependence for the preceding 3 years. Disulfiram discontinuation lead to an immediate symptomatic improvement.

CONCLUSION

Physicians initiating long-term disulfiram therapy should be aware of these adverse effects. They should recommend annual ophthalmic reviews with visual field testing. Patients should be reassured with respect to the reversibility of these adverse effects.

Safety issues concerning the use of disulfiram in treating alcohol dependence

Disulfiram is known to cause hepatitis, which is sometimes fatal. The best estimate of the frequency of disulfiram-induced fatal hepatitis is 1 case in 30,000 patients treated/year. Its appears to be more common in patients given disulfiram for the treatment of nickel sensitivity. Frequent blood testing for liver function is probably not necessary, but patients taking disulfiram should be in regular contact with a physician. There are rare reports of psychosis and confusional states in conjunction with disulfiram treatment and peripheral neuropathy and optic neuritis have been reported; these effects are dose-related. Psychiatric complications appear to be more common with the use of disulfiram in India than in Western countries. Of the less serious adverse effects, tiredness, headache and sleepiness are the most common. Deaths from the disulfiram-alcohol (ethanol) interaction have not been reported in recent years, possibly because the dosages used are lower than those used 40 years ago, and patients with cardiac disease are now excluded from treatment. There is no evidence to suggest that disulfiram causes cancer. Of note, there are drug interactions with compounds that utilise the cytochrome P450 enzyme system. Disulfiram can be viewed as a drug with a moderate record of adverse effects. Alcohol dependence, for which it can be a helpful treatment, is associated with a high morbidity and mortality.

Disulfiram causes sustained behavioral and biochemical effects in rats

The present experiment examined effects of disulfiram (Antabuse) administration on behavioral measures of nociception (hot plate and tail flick), peripheral muscular performance (grip strength), motivated performance, balance, and coordination (rotorod) in 24 male Sprague-Dawley rats during and 2 wk after an eight-day administration of disulfiram. In addition, peptidylglycine 5(-hydroxylating monooxygenase (PHM) activity in several tissues and levels of alpha-amidated alpha-melanocyte stimulating hormone (alpha-MSH) in the neurointermediate lobe of the pituitary were assayed to evaluate biochemical effects of disulfiram. These particular assays were included because it has been reported that disulfiram affects alpha-amidated peptides via alteration of PHM activity. Decrements in all behavioral measures, except tail flick, occurred after one week of disulfiram administration. Decrements in grip strength continued for the 2 wk after cessation of disulfiram. Dose-related reductions in changes in PHM activity and levels of alpha-MSH were found 2 wk after cessation of disulfiram administration. The time course of the results suggest that changes in PHM activity may underlie decrements in grip strength. The present experiment provides a paradigm for further investigations of effects of alpha-amidated peptides on behavior.

Prevention and management of drug-induced peripheral neuropathy

When symptoms of peripheral neuropathy appear, the possibility that they have been induced by drugs should be considered. A large number of drugs of all kinds, several of which are considered indispensable, have been implicated in peripheral neuropathy. A list of some of these drugs is provided. Neuropathy is a universal and dose-limiting factor during treatment with vinca alkaloids, but is otherwise a rare complication of drug therapy. Drug-induced peripheral neuropathy is almost always due to a dose-dependent primary axonal degeneration caused either by toxic reactions or by metabolic changes in neurons or their surroundings. The use of drugs should be restricted, especially in patients with a risk for development of neuropathy or with already existing neuropathy, e.g. patients with hepatic or renal failure, diabetes mellitus, or malnutrition. Patients should be given vitamins, prophylactically or therapeutically, which will sometimes allow a treatment to be continued. In other cases of drug-induced neuropathy the drug should be stopped. Reversal depends on the severity of the neuropathy, intensity and duration of the treatment and existence of causative cofactors, but generally the prognosis is good. While waiting for recovery physiotherapy is of importance, and when paraesthesia and pain are troublesome the patient should be treated with carbamazepine, imipramine or lidocaine (lignocaine).

Disulfiram treatment of alcoholism

PURPOSE

For 40 years, disulfiram has been the alcohol-aversive drug used most frequently by American physicians in the treatment of alcohol dependency disorders. We reviewed the clinical literature regarding the risks, benefits, indications, and efficacy of this controversial drug and summarized current knowledge of this therapy.

CONCLUSIONS

Disulfiram will produce an aversive reaction with ethanol, usually at a dose between 250 mg/day and 500 mg/day, although some patients may not have an aversive reaction at this level. Cardiac, hepatic, and neurologic toxicity can also occur within this dosage range. If disulfiram is to be used, the patient must clearly understand the risks of drinking while taking the drug, and the physician and patient must agree about the need for continued clinical supervision and monitoring for efficacy and side effects. The physician must also recognize that disulfiram is only an adjunctive therapy and that continued support, supervision, and other therapeutic measures are required. Disulfiram is probably effective in reducing the frequency of alcohol consumption in the compliant patient over the short term (e.g., 6 months). Certain subgroups of patients, such as those who are older, those who are more socially stable, and those who are well-motivated, may experience a beneficial effect for longer periods. The drug may be most effective in reducing short-term alcohol consumption when the compliance of the patient is supervised, although consideration of this kind of therapy includes the practical problems of supervising the patient and concerns that the supervising person may be placed in a difficult position. Prescription of disulfiram without accompanying education, counseling, and concomitant alcoholism therapy is not beneficial. Disulfiram has no proven effect on the long-term outcome of alcoholism.

Treatment of peripheral neuropathies

There are three general approaches to treatment of peripheral neuropathy. First, an attempt should be made to reverse the pathophysiological process if its nature can be elucidated. Second, nerve metabolism can be stimulated and regeneration encouraged. Third, even if the neuropathy itself cannot be improved, symptomatic therapy can be employed. This review outlines the options available for each approach.

Reversible, late-onset disulfiram-induced neuropathy and encephalopathy

Disulfiram toxicity is a well-recognized cause of peripheral neuropathy and encephalopathy, usually developing within a few months of the start of therapy. We describe a patient who insidiously developed a peripheral neuropathy and encephalopathy after thirty years of disulfiram ingestion. Both complications partially resolved after the medication was stopped.

Disulfiram polyneuropathy

Disulfiram in generally accepted maintenance doses in alcoholism may produce a rather severe polyneuropathy. In addition to the 39 literature cases, 5 personal patients were examined. Detailed clinical findings are given and the frequent permanent sequelae are emphasized. In 2 patients sural nerve biopsies were studied (including electromicroscopical examination) revealing a primary axonal lesion. In the treatment of alcohol addiction one should be aware of this complication.

[Polyneuropathy caused by disulfiram poisoning]

Disulfiram is known to produce toxic encephalopathy and peripheral neuropathy. The case of a 37-year-old alcoholic who attempted to commit suicide by taking 22.5 g disulfiram is described. During the first 6 days after the intoxication he was stuporous and had cerebellar ataxia and dysarthric speech. Then he became comatose, and as he recovered from coma, he showed peripheral neuropathy including diplegia faciei and severe tetraparesis. Denervation potentials were detected in both facial muscles and distal muscles of the upper and lower limbs, while conduction velocity was normal. Axonal degeneration was verified by sural nerve biopsy. In addition neurofilamentous axonopathy was documented. The recovery from his paresis lasted 2 years.

Peripheral neuropathy after disulfiram administration: reversibility despite continued therapy

The clinical history of an abstinent alcoholic developing paresthesias after one year's treatment with disulfiram (250 mg daily) is presented. Despite continued disulfiram in decreased dosage (125 mg daily), associated with multivitamin supplementation, marked improvement in symptoms and signs was noted, contrary to previous case reports. The peripheral sensorimotor neuropathy associated with disulfiram administration has been well described [1 - 8]. From those reports, it appears that symptoms may appear from several weeks to several months after the drug has been administered. Although the etiology of this neuropathy remains speculative, the usual treatment is to discontinue disulfiram once the toxicity develops. Presented here is the clinical course of a subject, whose neuropathic symptoms resolved with continued disulfiram administration at a lower daily dosage in conjunction with multivitamin therapy.

Disulfiram neuropathy. A morphometric study of sural nerve

This report describes peripheral nerve morphology in 3 patients whose acute polyneuropathy followed disulfiram therapy. In all patients a combination of axonal degeneration with segmental demyelination and remyelination was seen, suggesting a varying degree of toxicity to both cytons and Schwann cells. The observed randomness of abnormal internodes argued against primary axonal atrophy and secondary demyelination. While large myelinated fibres were preferentially lost, ultrastructural studies also suggested degeneration of unmyelinated fibres. Because of high chloral consumption at the onset of peripheral nerve disease in 2 patients, the possibility of disulfiram-chloral interaction was considered. Present evidence suggests that the combined use of chloral or its derivatives with disulfiram is best avoided.

Peripheral neuropathy associated with disulfiram administration

Very few cases of peripheral neuropathy as a complication of disulfiram therapy have been described. The clinical and electrodiagnostic features of two patients who developed a severe peripheral neuropathy during disulfiram administration are reported. Evidence is presented which suggests that disulfiram causes a dying-back axonal neuropathy.

Peripheral neuropathy after disulfiram administration

Peripheral neuropathy and optic neuritis occurring in alcoholics are sometimes due to the toxic effects of disulfiram rather than to alcohol. Unless this is considered in the management of such patients it is likely that administration of the drug will be continued. In the past there have been reports of 16 cases of peripheral neuropathy and six cases of optic neuritis, possibly caused in this way; these reports are reviewed and a further six cases are described. The effects of disulfiram on the nervous system are briefly discussed.