Disulfiram-alcohol reaction: symptoms, risks and safety advice

Disulfiram is one of the medicines used for alcohol-use disorder. The NHS lists it alongside acamprosate and naltrexone, which help reduce cravings, and describes disulfiram as causing unpleasant effects when combined with alcohol. These medicines are usually offered once you have stopped drinking and need help staying sober.

The reaction is the point of the medicine, because the expectation of feeling ill discourages drinking, but it is also the main danger. The BNF warns that symptoms may be severe and life-threatening, which is why disulfiram is used with careful assessment and support.

The NHS lists headache, feeling sick, high body temperature and heart palpitations. The BNF patient advice adds flushing, arrhythmias, low blood pressure, respiratory depression and coma as possible features, and NICE lists flushing, nausea, palpitations and, more seriously, arrhythmias, hypotension and collapse.

The reaction is described as potentially rapid and unpredictable, so a person who has taken alcohol while on disulfiram and feels unwell should treat it as a medical emergency rather than waiting to see how it develops.

• Flushing, headache and a sense of heat.

• Nausea and vomiting.

• Palpitations or an irregular heartbeat.

• Low blood pressure, feeling faint or collapse.

• Breathing difficulty or reduced consciousness in severe reactions.

The BNF says reactions may occur after exposure to small amounts of alcohol in perfume, aerosol sprays, or low alcohol and non-alcohol beers and wines. NICE similarly tells prescribers to warn service users and their families and carers about the interaction with alcohol, which may also be found in food, perfume and aerosol sprays.

In practice, this means reading labels carefully, asking the pharmacist about alcohol content in medicines such as some liquid preparations and mouthwashes, and being cautious with sauces and desserts that use alcohol. Your prescriber or pharmacist can advise on specific products.

NICE guideline CG115 recommends a comprehensive medical assessment before starting, including baseline urea and electrolytes and liver function tests, and checking the product information for cautions in pregnancy and in people with a history of severe mental illness, stroke, heart disease or high blood pressure. The BNF lists contra-indications including cardiac failure, coronary artery disease, previous stroke, hypertension, psychosis and suicide risk.

NICE says people taking disulfiram should stay under supervision at least every 2 weeks for the first 2 months, then monthly for the following 4 months if possible, have an informed family member or carer oversee administration, and be medically monitored at least every 6 months afterwards. The BNF gives the same monitoring schedule.

The BNF lists possible side effects including drowsiness, fatigue, depression, nausea, breath odour and hepatocellular injury. It states that treatment should be discontinued and medical advice sought if signs of liver problems develop.

Call 999 or go to A&E if someone taking disulfiram has drunk alcohol and has chest pain, palpitations, collapses, has difficulty breathing or becomes drowsy or unresponsive. Seek urgent medical attention, as NICE advises, if you feel unwell or develop a fever or jaundice (yellowing of the skin or eyes) while taking disulfiram, and stop taking it until you have been assessed.

Disulfiram is prescribed and monitored by NHS drug and alcohol services or specialist addiction teams, often with a GP, and the NICE-recommended monitoring is part of that care. Private addiction clinics also prescribe it, and in either setting the assessment, psychological support and regular monitoring are essential parts of treatment, not optional extras.