February 27, 2020
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Call to action: Set new standards for alcohol-associated hepatitis transplant

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Norah Terrault

MAUI, Hawaii — To better manage alcohol-associated hepatitis, standards for the liver transplantation process should be altered as liver transplantation gains support as a therapeutic option for this disease, according to an expert at GUILD Conference 2020.

“It was always there for individuals who develop alcohol cirrhosis and/or liver cancer, but alcohol-associated hepatitis [AH] is now recognized as a potential indication for liver transplantation,” Norah Terrault, MD, MPH, professor of medicine at Keck Medical Center at the University of Southern California, said during her presentation.

Terrault reported on a study about the influence of corticosteroids and pentoxifylline on the mortality rate of patients with severe acute AH. Data showed corticosteroids bested placebo and that there was no benefit in simultaneously taking corticosteroids and pentoxifylline. Terrault argued these results indicate a need for new therapy developments that have not been seen in decades.

She also cited a study that showed post-transplant alcohol abstinence was achievable even if the standard 6-month abstinence period pre-transplant was not met. Terrault said these data suggest pre-transplant abstinence should not be mandatory, adding that the data also showed it was not a better predictor of abstinence post-transplant than psychosocial factors like employment and a good support system.

Additionally, Terrault shared results from a retrospective Accelerate Consortium study that observed that 70% of patients were abstinent 5 years post- transplant, even without abstaining from alcohol use for 6 months before the transplant.

Terrault reasoned it was imperative to establish how to select patients with the most potential for abstinence post-transplant and how to do so objectively, noting several predictors of alcohol use post- transplant. These include history of multiple transplant attempts, young age and severe encephalopathy.

She reported that patients at most risk for early heavy use of alcohol after transplantation were young people; and for those older than 35 years, higher risk patients included, women, people with obesity and Hispanic people. Terrault said those who would be most prone to relapsing “would need a more intensified program to manage their alcohol use disorder post-transplant.”

Because patients with alcohol-associated hepatitis often present at a more advanced stage of disease, those approved for liver transplants could be bumped to the top of the transplant wait list. This may cause patients with progressive chronic diseases to die before receiving a transplant. Terrault argued that similar actions are taken for other diseases.

“Alcohol is a chronic disease. And instead of being surprised that they’re drinking, we should be surprised at the number that are abstinent, actually,” Terrault said. “Alcohol use disorder is one that needs to be managed, just like we manage diabetes or other chronic conditions.” – by Kalie VanDewater

References:

Terrault N. Acute alcohol-associated hepatitis: Controversies in management. Presented at: GUILD Conference; February 16-19, 2020; Maui, Hawaii.

Disclosures: Terrault reports receiving grant support from Gilead Sciences.