Anticol tablets

Anticol is an oral medication containing disulfiram in a dose of 500 mg — the same active substance found in the Esperal alcohol implant. The difference lies in the form of administration: Anticol is a tablet taken daily, while Esperal is an implant placed subcutaneously during a surgical procedure.

Disulfiram works on the principle of aversion therapy. It blocks the enzyme aldehyde dehydrogenase, which under normal conditions converts toxic acetaldehyde (a metabolite of ethyl alcohol) into harmless acetic acid. In a person taking Anticol, even a small amount of alcohol causes rapid accumulation of acetaldehyde in the blood — and immediate, very unpleasant symptoms of poisoning.

Simplifying the entire process:

• Without Anticol: Alcohol → Acetaldehyde → Acetic acid → Water + CO₂ (the body copes with alcohol)
• With Anticol: Alcohol → Acetaldehyde ✕ (conversion blocked!) → toxin accumulation → disulfiram reaction

The goal of treatment is not to physically prevent drinking, but to create a strong psychological aversion. The patient knows that consuming alcohol will trigger immediate, very unpleasant symptoms — and this awareness serves as a powerful motivation to maintain abstinence.

Anticol and Esperal (alcohol implant) contain the same active substance — disulfiram. The key difference lies in the method of administration and its practical consequences:

Method of administration and duration of action

• Anticol (tablets) — taken orally, daily. The medication works only as long as the patient takes it. The patient can stop treatment at any time — which is both an advantage (control) and a risk (abandoning therapy under impulse).
• Esperal (implant) — a one-time surgical procedure, after which the medication releases on its own for 8–12 months. The patient cannot interrupt the medication's action — which eliminates the problem of discipline.

Dosage

• Anticol: 500 mg/day at start, then 250 mg/day (range 125–500 mg)
• Esperal: 8–10 tablets × 100 mg implanted subfascially as a single procedure

Required abstinence

• Anticol: minimum 24 hours without alcohol before the first tablet
• Esperal: minimum 12 hours (SmPC requirement), in our clinic's practice — 24 hours

Alcohol ban after completion

• Anticol: 14 days after the last tablet
• Esperal: until the implant is depleted (8–12 months)

Contraindications

• Anticol has a wider list of absolute contraindications — diabetes, severe respiratory failure, renal and hepatic failure are exclusions for Anticol, while for Esperal they only require caution.

Pregnancy

• Anticol: absolutely contraindicated in pregnancy
• Esperal: 1st trimester — no; 2nd–3rd trimester — consider benefit-risk balance

The choice between Anticol and Esperal is a key therapeutic decision. Here are guidelines that help the doctor select the appropriate form:

Anticol (oral tablets) — better choice when:

• The patient wants to maintain control over treatment — ability to stop and resume therapy
• There are contraindications to surgical procedure — wound healing problems, anticoagulant medications, haemophilia
• The patient prefers a gradual approach — the doctor can flexibly adjust the dose (125–500 mg)
• The doctor wants to test disulfiram tolerance — before a potential Esperal implant procedure
• The patient is at the beginning of the therapeutic path — Anticol allows "testing" disulfiram before committing to the longer-lasting form

Esperal (implant) — better choice when:

• The patient has difficulty taking medications systematically — the implant eliminates this problem entirely
• Stronger "safeguard" against impulsive reaching for alcohol is needed
• The patient has had multiple relapses — the fact that the medication cannot be discontinued is additional motivation
• The patient consciously wants to "cut off the escape route" — some patients need this certainty

In many cases, the doctor starts with Anticol to assess the patient's tolerance to disulfiram, and then suggests transitioning to Esperal (implant) if the patient wants long-term protection.

Anticol should always be used strictly according to the doctor's instructions. Self-modification of the dose is unacceptable.

Treatment phases

• Initial phase (1–2 weeks): 500 mg per day (1 tablet). This is the highest and simultaneously the maximum permissible daily dose.
• Maintenance phase: 250 mg per day (half a tablet). The doctor may adjust the dose within the range of 125–500 mg depending on the individual patient's response.

Practical tips

• Time of administration: the tablet is taken once daily, preferably in the morning.
• If severe drowsiness occurs: the doctor may recommend moving the dose to the evening hours.
• Condition for starting: treatment can be started at the earliest after 24 hours from the last contact with alcohol (in any form).
• Duration of therapy: determined individually by the treating physician. There is no established "standard" treatment length — it depends on therapy progress and the patient's situation.

Important: Missing a dose does not mean the patient is "safe" — disulfiram and its metabolites remain in the body for up to 14 days after the last tablet. Under no circumstances should a missed dose be made up with a double dose.

A disulfiram reaction is a set of very unpleasant symptoms that appear after alcohol consumption by a person taking Anticol. This is the intended treatment effect — but in severe cases it can pose a threat to health and even life.

Time course of the reaction

• Onset: symptoms appear within 15 minutes of alcohol consumption
• Peak intensity: after 30–60 minutes
• Resolution: gradually over several hours, after which the patient usually falls into a deep, prolonged sleep

Typical symptoms (occur almost always)

• Intense facial and neck flushing — caused by sudden dilation of blood vessels
• Rise in body temperature and profuse sweating
• Nausea and vomiting — often violent and repeated
• Skin itching and urticaria
• Visual disturbances
• Heart palpitations (tachycardia), breathlessness and hyperventilation (rapid breathing)
• Dizziness and severe headache
• Anxiety, fear, general malaise

Severe symptoms — life-threatening!

When a large amount of alcohol is consumed, symptoms may occur that require immediate medical assistance:

• Rapid heartbeat, sudden drop in blood pressure (hypotension)
• Respiratory depression — breathing difficulties
• Chest pain, cardiac arrhythmias
• ECG changes: QT prolongation, ST depression
• Seizures, loss of consciousness, coma

Rare symptoms

• Arterial hypertension (paradoxical blood pressure increase instead of decrease)
• Bronchospasm
• Methemoglobinemia (impaired oxygen transport in the blood)

In sporadic cases, when medical help is not provided — the disulfiram reaction can lead to death. That is why it is so important that the patient and their close ones know how to respond in an emergency: immediately call emergency services (112 or 999) and inform paramedics about the use of disulfiram.

One of the most important pieces of information that the patient must remember is the 14-day waiting period after stopping Anticol.

Disulfiram and its active metabolites remain in the body for two weeks after the last tablet. During this time, the disulfiram reaction is still fully possible — the patient is not "free" from the medication's action.

Hidden sources of alcohol that can trigger a reaction

Symptoms of alcohol intolerance can occur not only after drinking alcoholic beverages but also after using liquids containing alcohol. The leaflet lists the following examples:

• Mouthwash solutions
• Sauces and vinegar
• Cough syrups
• Warming products
• Aftershave, perfumes and other cosmetics

Caution should also be exercised when consuming products containing small amounts of alcohol or non-alcoholic beers and wines, as they may trigger a disulfiram-alcohol reaction.

Additionally, contact with organic solvents containing alcohol, acetaldehyde or paraldehyde (e.g., used for thinning paints, petrol) during disulfiram treatment may trigger a disulfiram reaction.

The list of absolute contraindications for Anticol is wider than for Esperal (implant). Several conditions that require only caution with the implant are absolute exclusions for Anticol.

Absolute contraindications (must not use)

• Hypersensitivity to disulfiram, thiocarbamates or excipients of the medication
• Alcohol within the last 24 hours — applies to alcoholic beverages, state of intoxication and medications containing ethanol
• Heart failure, ischaemic heart disease, arterial hypertension, history of stroke
• Severe respiratory failure — for Esperal this is only a caution
• Severe hepatic failure — for Esperal this is only a caution
• Renal failure — for Esperal this is only a caution
• Diabetes — for Esperal this is only a caution
• Psychiatric disorders: psychoses (except past alcohol-related psychoses), history of suicide attempts

Conditions requiring special caution

The following conditions do not exclude Anticol treatment, but the doctor must take them into account — a potential disulfiram reaction may worsen their course:

• Respiratory diseases (asthma, COPD)
• Hypothyroidism
• Brain damage or history of head trauma
• Epilepsy
• Kidney and/or liver diseases (of lesser severity than "severe failure")

Critically important: Anticol must not be administered without the patient's informed consent. Under no circumstances should disulfiram be given to a person who does not know they are taking it — this is not only unethical but also legally prohibited.

Disulfiram enters into significant interactions with many medications. Before starting Anticol treatment, you must inform the doctor about all medications you are taking — including those available without prescription.

Absolutely contraindicated combination

• Metronidazole (antibiotic used, among other things, for vaginal, intestinal and dental infections) — combining with Anticol can lead to states of disorientation, psychotic episodes and confusion. These two medications must never be combined under any circumstances.

Medications whose action Anticol enhances (risk of overdose)

• Anticoagulants (e.g., warfarin, acenocoumarol) — Anticol inhibits their metabolism, increasing the risk of bleeding. More frequent INR monitoring is necessary.
• Antipyrine (analgesic and antipyretic) — enhanced action.
• Phenytoin (anti-epileptic) — enhanced action, risk of toxicity (dizziness, double vision, ataxia).
• Diazepam, chlordiazepoxide (benzodiazepines) — enhanced sedation, excessive drowsiness.
• Alfentanil (anaesthetic) — prolonged duration of action.
• Pethidine, morphine, amphetamine — similar effect on hepatic metabolism (data from animal studies).

Medications that modify the course of the disulfiram reaction

• Amitriptyline (antidepressant) — enhances the symptoms of the disulfiram reaction, making it more dangerous.
• Diazepam, chlordiazepoxide — weaken the reaction symptoms, which paradoxically can be dangerous (false sense of safety).
• Chlorpromazine — partially weakens some symptoms but may overall enhance the course of the reaction.

Other important interactions

• Rifampicin (tuberculosis medication) — inhibition of oxidation and renal excretion.
• Isoniazid (tuberculosis medication) — dizziness, motor coordination disorders, irritability, insomnia.

Anticol can cause side effects even in persons maintaining full abstinence. Most of them are transient and subside within the first weeks of treatment, but the patient should be aware of them.

Common symptoms at the start of treatment (usually transient)

• Drowsiness and fatigue — especially in the first days; if severe, the doctor may recommend moving the dose to the evening
• Metallic or garlic taste in the mouth — characteristic of disulfiram
• Bad breath — results from the metabolism of the medication, not from oral hygiene

Less common but more serious

• Psychiatric disorders: depression, paranoia, mania, decreased libido, psychotic reactions — occur rarely but require immediate contact with the doctor
• Neurological disorders: peripheral neuritis (numbness, tingling in extremities), optic neuritis (visual disturbances), encephalopathy
• Gastrointestinal disorders: nausea, vomiting
• Liver cell damage — requires monitoring of liver enzymes
• Allergic dermatitis
• Transient impotence

Any concerning symptom should be reported to the treating physician. Do not stop treatment on your own — consult every change with the doctor.

Anticol overdose is rare but potentially dangerous. A characteristic feature is the delayed onset of the most severe symptoms — even several days after the overdose, with slow recovery and possible long-term consequences.

Early symptoms (first 12 hours)

• Nausea, vomiting, abdominal pain, diarrhoea
• Drowsiness, lethargy, delirium, hallucinations

Severe symptoms

• Rapid heartbeat (tachycardia) and rapid breathing
• Hyperthermia (dangerously elevated body temperature)
• Hypotension (especially in children), decreased tendon reflexes
• Hyperglycaemia, leucocytosis, ketosis, methemoglobinaemia
• Circulatory collapse, coma, seizures

Delayed symptoms (days after overdose!)

This is what makes disulfiram overdose particularly insidious:

• Sensorimotor neuropathy (peripheral nerve damage)
• EEG abnormalities, encephalopathy (brain damage)
• Psychoses, catatonia, immobility
• Speech disorders, myoclonic jerks, ataxia (coordination disorders), dystonia

Management in case of overdose

The doctor will apply symptomatic treatment and monitor the patient's condition. Gastric lavage and/or activated charcoal may be considered. In case of intense vomiting, intravenous fluids are necessary.

In case of suspected overdose, immediately call emergency services (112 or 999). Inform paramedics that the patient is taking disulfiram — this information is crucial for proper management.

Pregnancy

Anticol is absolutely contraindicated in pregnancy — regardless of the trimester. This is a stricter position than for Esperal (implant), where in the 2nd–3rd trimester a benefit-risk balance may be considered.

Women of childbearing age should use effective contraception during Anticol treatment and for 14 days after the last dose.

Breastfeeding

Anticol should not be used during breastfeeding. There is insufficient data on the passage of disulfiram and its metabolites into breast milk — the risk to the infant cannot be excluded. This is particularly relevant when there is a possibility of interaction between disulfiram and medications that may be used in the child.

Driving and operating machinery

Anticol can cause drowsiness and fatigue, particularly at the start of treatment. The patient should make sure how the medication affects their ability to concentrate before getting behind the wheel.

This is a stricter warning than for Esperal — the implant's SmPC states that the effect on driving is "unlikely", while the Anticol leaflet clearly recommends caution.

Anticol treatment requires a prescription — the medication is not available over the counter at the pharmacy. Here is how the process of starting therapy looks:

1. Medical consultation — in-person or online. The doctor conducts a medical interview, verifies contraindications and establishes an individual treatment plan.
2. Issuing an e-prescription — if there are no contraindications, the doctor issues an electronic prescription that the patient can fill at any pharmacy.
3. Minimum 24 hours of abstinence — at least 24 hours must pass from the last contact with alcohol before the first tablet.
4. Starting treatment — first dose: 500 mg (1 tablet) in the morning.
5. Regular follow-up visits — the doctor monitors medication tolerance and adjusts the dose.

Anticol is most effective when used as part of comprehensive therapy — in combination with addiction psychotherapy, group support and regular contact with a therapist.

The medication will not cure addiction on its own — but it gives the patient a valuable "sobriety window" during which they can work on the causes of their drinking and build new coping strategies.