In the Journals

Alcohol use disorder therapy could improve chronic liver disease outcomes

Details from a recently published review discussed expanded use of alcohol use disorder medications and treatments in everyday clinical practice for patients with advanced liver disease.

“Alcohol use is a major cause of preventable liver disease worldwide, and alcoholic liver disease is the main alcohol-related chronic medical illness,” Daniel Fuster, MD, PhD, from the Autonomous University of Barcelona in Spain, and Jeffrey H. Samet, MD, MPH, from the Boston University School of Medicine and Public Health in Boston and chief of General internal medicine at Boston Medical Center, wrote in their review. “Globally, per capita alcohol consumption is strongly correlated with the rate of death due to liver cirrhosis.”

Fuster and Samet first outlined the affects of alcohol use on four of the most prevalent forms of liver disease: hepatitis C, hepatitis B, nonalcoholic fatty liver disease, and hereditary hemochromatosis.

In HCV, alcohol use increases infection exposure and persistence, causes more extensive liver damage than the infection alone, leads to faster progression of liver fibrosis and results in higher rates of mortality. These effects are common in HBV as well, although alcohol use in patients with HBV also demonstrated an increased risk for hepatocellular carcinoma.

Along with increased fibrosis progression and an increased risk for hepatocellular carcinoma, alcohol use in patients with NAFLD leads to a greater prevalence of steatosis and abnormal liver tests. In hereditary hemochromatosis, alcohol use increases fibrosis progression as well as iron overload.

“Assessment of alcohol use is appropriate for any person with liver disease, given the elevated risks of alcohol-related hepatotoxicity,” Fuster and Samet wrote. “In fact, there is no known safe threshold of alcohol consumption for patients with chronic liver disease, especially those with HCV infection, obesity, or the metabolic syndrome.”

The authors advised that the Alcohol Use Disorders Identification Test (AUDIT), recommended by both American and European guidelines, and the National Institute on Alcohol Abuse and Alcoholism single-question screening tool have been validated for the screening of unhealthy alcohol use in the primary care setting.

Regarding medical treatment for alcohol-use disorder, specifically alcohol withdrawal, long-acting benzodiazepines protect against seizures and delirium. Short- and intermediate-acting benzodiazepines have similar effects as long-acting options but are safer for patients with poor synthetic liver function. Carbamazepine and oxcarbazepine can help mitigate symptoms in uncomplicated withdrawal cases, although they have not demonstrated the same quality as benzodiazepines.

“Several nonpharmacologic strategies for relapse prevention can be implemented in primary care,” Fuster and Samet explained. “These include establishing a supportive patient–physician relationship; scheduling regular follow-up visits; mobilizing family support; suggesting involvement in 12-step programs; developing a plan to recognize, cope with, and manage early relapse; facilitating positive lifestyle changes; and treating coexisting conditions that can trigger relapse.”

In cases of end-stage liver disease, liver transplantation is an effective response with similar graft survival rates in patients with alcoholic liver disease compared with other patients. While most guidelines promote a minimum of 6-months alcohol abstinence as a prerequisite for receipt of a liver transplant, empirical data for this approach has been mixed.

Relapse is a concern, of course, but Fuster and Samet state that recidivism ranged in recent studies between 15% and 20%.

“These data could be informative in consideration of the development of an alternative approach for persons with alcohol-use disorder and liver failure, which has been explored recently by other groups, with promising results,” the authors wrote. “It would be wise to expand alcohol-use disorder treatment in everyday clinical practice to include treatment in patients with advanced liver disease.” – by Talitha Bennett

Disclosure: The authors report no relevant financial disclosures.

Details from a recently published review discussed expanded use of alcohol use disorder medications and treatments in everyday clinical practice for patients with advanced liver disease.

“Alcohol use is a major cause of preventable liver disease worldwide, and alcoholic liver disease is the main alcohol-related chronic medical illness,” Daniel Fuster, MD, PhD, from the Autonomous University of Barcelona in Spain, and Jeffrey H. Samet, MD, MPH, from the Boston University School of Medicine and Public Health in Boston and chief of General internal medicine at Boston Medical Center, wrote in their review. “Globally, per capita alcohol consumption is strongly correlated with the rate of death due to liver cirrhosis.”

Fuster and Samet first outlined the affects of alcohol use on four of the most prevalent forms of liver disease: hepatitis C, hepatitis B, nonalcoholic fatty liver disease, and hereditary hemochromatosis.

In HCV, alcohol use increases infection exposure and persistence, causes more extensive liver damage than the infection alone, leads to faster progression of liver fibrosis and results in higher rates of mortality. These effects are common in HBV as well, although alcohol use in patients with HBV also demonstrated an increased risk for hepatocellular carcinoma.

Along with increased fibrosis progression and an increased risk for hepatocellular carcinoma, alcohol use in patients with NAFLD leads to a greater prevalence of steatosis and abnormal liver tests. In hereditary hemochromatosis, alcohol use increases fibrosis progression as well as iron overload.

“Assessment of alcohol use is appropriate for any person with liver disease, given the elevated risks of alcohol-related hepatotoxicity,” Fuster and Samet wrote. “In fact, there is no known safe threshold of alcohol consumption for patients with chronic liver disease, especially those with HCV infection, obesity, or the metabolic syndrome.”

The authors advised that the Alcohol Use Disorders Identification Test (AUDIT), recommended by both American and European guidelines, and the National Institute on Alcohol Abuse and Alcoholism single-question screening tool have been validated for the screening of unhealthy alcohol use in the primary care setting.

Regarding medical treatment for alcohol-use disorder, specifically alcohol withdrawal, long-acting benzodiazepines protect against seizures and delirium. Short- and intermediate-acting benzodiazepines have similar effects as long-acting options but are safer for patients with poor synthetic liver function. Carbamazepine and oxcarbazepine can help mitigate symptoms in uncomplicated withdrawal cases, although they have not demonstrated the same quality as benzodiazepines.

“Several nonpharmacologic strategies for relapse prevention can be implemented in primary care,” Fuster and Samet explained. “These include establishing a supportive patient–physician relationship; scheduling regular follow-up visits; mobilizing family support; suggesting involvement in 12-step programs; developing a plan to recognize, cope with, and manage early relapse; facilitating positive lifestyle changes; and treating coexisting conditions that can trigger relapse.”

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In cases of end-stage liver disease, liver transplantation is an effective response with similar graft survival rates in patients with alcoholic liver disease compared with other patients. While most guidelines promote a minimum of 6-months alcohol abstinence as a prerequisite for receipt of a liver transplant, empirical data for this approach has been mixed.

Relapse is a concern, of course, but Fuster and Samet state that recidivism ranged in recent studies between 15% and 20%.

“These data could be informative in consideration of the development of an alternative approach for persons with alcohol-use disorder and liver failure, which has been explored recently by other groups, with promising results,” the authors wrote. “It would be wise to expand alcohol-use disorder treatment in everyday clinical practice to include treatment in patients with advanced liver disease.” – by Talitha Bennett

Disclosure: The authors report no relevant financial disclosures.