Six approved drugs for alcohol use disorder: algorithms for their use according to the aims of treatment

Background: The pharmacological management of alcohol use disorder (AUD) currently includes six medications approved by different regulatory agencies worldwide: acamprosate (ACM), naltrexone (NTX), nalmefene (NMF), disulfiram (DF), baclofen, and sodium oxybate (SO). Their optimal use should be aligned with the main aims of treatment, namely reduction of alcohol consumption and maintenance of complete abstinence. Objectives: This brief review summarizes the role of these six approved medications in AUD treatment and proposes practical treatment algorithms according to treatment goals, mechanisms of action, and clinically relevant outcomes. Methods: A focused narrative review of the literature was conducted, prioritizing meta-analyses, systematic reviews, randomized controlled trials, and relevant regulatory documents. Evidence on efficacy, safety, tolerability, and clinical applicability was interpreted pragmatically to support first-, second-, and third-line pharmacological strategies. Results: For reducing alcohol intake, NMF or NTX are proposed as first-line pharmacotherapies, with baclofen considered as a second-line option when these agents are partially effective or ineffective. For maintaining abstinence, ACM is proposed as a first-line strategy. In selected clinical settings, including severe AUD, protracted alcohol withdrawal syndrome, high motivation for aversive treatment, or liver disease, SO, baclofen, DF, or NTX may serve as second-line options. Combined pharmacotherapy may be considered in highly adherent patients, whereas off-label drugs remain third-line options for refractory cases. Conclusions: Improved knowledge of the efficacy, safety, and tolerability of the six approved medications may support more appropriate, individualized, and goal-oriented pharmacological management of patients with AUD. The proposed algorithms are intended as pragmatic tools to aid clinical decision-making rather than as formal guidelines.