Alcohol withdrawal risk — MCCQE Part 1 MCQ

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HardSubstance UseAlcohol withdrawal riskMCCQE Part 1

A 58-year-old with severe alcohol use disorder has decompensated cirrhosis with jaundice and ascites. He has completed withdrawal treatment, wants an abstinence-oriented medication, takes no opioids, and has eGFR 82 mL/min/1.73 m². Which option is most appropriate?

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Correct answer: B — Acamprosate with adherence counselling

Acamprosate is a first-line abstinence-supporting medication and is not hepatically metabolised, making it a reasonable choice in advanced liver disease when renal function is adequate. Its dosing burden and the need for adherence counselling should be discussed, and renal function must be checked because significant renal impairment requires adjustment or avoidance. Naltrexone is generally avoided in decompensated liver disease, while disulfiram can cause serious hepatotoxicity and is inappropriate here. Benzodiazepines treat acute withdrawal but are not maintenance therapy for alcohol use disorder and can worsen sedation and encephalopathy. Cirrhosis does not mean treatment should be withheld; medication should be paired with psychosocial care and longitudinal liver-disease management.

Reference: Canadian Guideline for the Clinical Management of High-Risk Drinking and Alcohol Use Disorder: https://helpwithdrinking.ca/wp-content/uploads/2023/10/FINAL-Canadian-AUD-guidelines_ENG.pdf