Alcohol Use Disorders in Alcoholic Liver Disease

Designing clinical trials to address alcohol use and alcohol-associated liver disease: an expert panel Consensus Statement

Most patients with alcohol-associated liver disease (ALD) engage in heavy drinking defined as 4 or more drinks per day (56 g) or 8 (112 g) or more drinks per week for women and 5 or more drinks per day (70 g) or 15 (210 g) or more drinks per week for men. Although abstinence from alcohol after diagnosis of ALD improves life expectancy and reduces the risk of decompensation of liver disease, few studies have evaluated whether treatment of alcohol use disorders will reduce progression of liver disease and improve liver-related outcomes. In November 2021, the National Institute of Alcohol Abuse and Alcoholism commissioned a task force that included hepatologists, addiction medicine specialists, statisticians, clinical trialists and members of regulatory agencies to develop recommendations for the design and conduct of clinical trials to evaluate the effect of alcohol use, particularly treatment to reduce or eliminate alcohol use in patients with ALD. The task force conducted extensive reviews of relevant literature on alcohol use disorders and ALD. Findings were presented at one in-person meeting and discussed over the next 16 months to develop the final recommendations. As few clinical trials directly address this topic, the 28 recommendations approved by all members of the task force represent a consensus of expert opinions.

Alcohol use disorder in community management of chronic liver diseases

Rising rates of alcohol use disorder (AUD) combined with increases in alcohol-related liver disease (ALD) and other liver disease have resulted in the need to develop alcohol management strategies at all levels of patient care. For those with pre-existing liver disease, whether ALD or others, attention to alcohol use treatment and abstinence becomes critical to avoiding worsening liver-related consequences. Modalities to help patients reduce or stop alcohol include screening/brief intervention/referral to treatment, various therapeutic modalities including cognitive behavioral therapy, motivational enhancement therapy and 12-step facilitation, and alcohol relapse prevention medications. Harm reduction approaches versus total abstinence may be considered, but for those with existing ALD, particularly advanced ALD (cirrhosis or acute alcoholic hepatitis), total abstinence from alcohol is the recommendation, given clear data that ongoing alcohol use worsens mortality and liver-related morbidity. For certain populations, alcohol cessation is even more critically important. For those with hepatitis C or NAFLD, alcohol use accelerates negative liver-related outcomes. In women, alcohol use accelerates liver damage and results in worsened liver-related mortality. Efforts to integrate AUD and liver disease care are urgently needed and can occur at several levels, with establishment of multidisciplinary ALD clinics for fully integrated co-management as an important goal.

Alcohol-Related Liver Disease Including New Developments

The prevalence of alcohol consumption, alcohol use disorder (AUD), and alcohol-related liver disease (ALD) has exponentially increased over the last several years and rates continue to increase. Significant alcohol use can cause progression from steatosis in the liver to inflammation, fibrosis, and eventually cirrhosis. Additional risk factors for the progression of ALD disease include gender, race, and genetic predisposition. As such, it is essential for clinicians to understand and implement screening tools for early diagnosis of both AUD and ALD and be aware of emerging novel treatment options.

Alcohol misuse in patients with alcohol-related liver disease: How can we do better? A narrative review of the literature

BACKGROUND

Ongoing alcohol use is strongly associated with progressive liver damage and higher mortality in patients with alcohol-related liver disease (ArLD). Reduction in alcohol use is therefore the cornerstone of treatment to improve the long-term outcome of these patients. However, a large proportion of patients continue to use alcohol and do not access or engage with alcohol treatment services after a diagnosis of ArLD. We reviewed the literature on factors associated with ongoing alcohol consumption among patients with ArLD to identify barriers or facilitators to their accessing alcohol treatment.

METHODS

A search of MEDLINE and EMBASE was conducted using search strategies relating to ArLD and the psychosocial factors hypothesized to influence alcohol reduction and/or abstinence.

RESULTS

There were few relevant studies pertinent to this population group. Several studies reported a high prevalence of mental health diagnoses associated with the severity of alcohol dependence. Social and environmental factors were shown to be important determinants of alcohol use. Common themes perceived as barriers to treatment from qualitative interviews with ArLD patients across studies included poor communication between the clinical team and patient, lack of symptoms recognized by patients themselves, and perceived loss of control over their condition.

CONCLUSIONS

We recommend that future clinical studies of patient cohorts with ArLD include detailed psychosocial assessments to capture information on mental health and social factors. Qualitative studies are required to explore the patient journey pre and post hospital admission, which should focus on identifying facilitators and barriers to accessing treatment. Well-designed, controlled studies are needed to identify patient, social, and environmental factors associated with relapse to alcohol use after a diagnosis of ArLD. These data will enable us to adapt our support for patients to enhance engagement with services and improve long-term outcomes.

Patient- and provider-level factors that underlie alcohol use disorder treatment offer and acceptance in veterans with cirrhosis

BACKGROUND

Untreated alcohol use disorder (AUD) is associated with poor cirrhosis outcomes. We evaluated factors associated with AUD treatment discussions and initiation in the Veterans Health Administration.

METHODS

Chart reviews were conducted for veterans with International Classification of Diseases codes for both cirrhosis and AUD who were receiving care at one of three large medical centers in 2020. Factors associated with a 1-year offer of AUD treatment and its acceptance were assessed using regression models, which included as covariates demographic characteristics, comorbidities, and depression, as measured by the patient health questionnaire (PHQ-2) from the electronic health record.

RESULTS

The cohort included 654 veterans, 68 of whom were engaged in AUD treatment at baseline and 174 who were documented as being in AUD remission. Treatment was offered to 264 (64%) of the 412 veterans with opportunities to initiate it. AUD treatment discussions were most often documented by practitioners in primary care (n = 162), hepatology (n = 45), or both (n = 41). Multivariable logistic regression modeling revealed that treatment was significantly more likely to be offered to patients with co-occurring bipolar disorder (OR 2.94, p = 0.03) or depression (1.50, p = 0.05) or who were younger (0.97, p = 0.01). Of the 264 patients offered AUD treatment, 107 (40%) agreed to initiate it. Acceptance of an offer of treatment was significantly associated with hospitalization in the prior year (OR 1.74, p = 0.05), prior AUD treatment (9.92, p < 0.0001), and a higher PHQ-2 depression score (2.85, p = 0.004).

CONCLUSIONS

We identified factors associated with an offer of AUD treatment and its initiation among veterans with cirrhosis. Application of these findings could increase the likelihood that veterans with alcoholic cirrhosis initiate AUD treatment.

Selection Criteria for Liver Transplantation for Acute Alcohol-Associated Hepatitis

Severe acute alcohol-associated hepatitis that is nonresponsive to medical therapy has an extremely high mortality. Liver transplantation is a feasible treatment option and available at certain transplant centers globally. Selection criteria for liver transplantation are not, uniform but there are important key criteria shared across protocols. Of equal importance to the management of liver disease is the treatment of alcohol use disorder. A thorough assessment of candidates involves input from an addiction specialist and psychiatrist. With careful selection practices, graft and patient survival among transplant recipients with severe alcohol-associated hepatitis is similar to other etiologies of chronic liver disease.

Moderate Alcoholic Hepatitis

The natural history of moderate alcoholic hepatitis (AH) is not well known. It is a frequent disease with a probable underestimated incidence compared with its severe form. Among the different prognostic scores predicting short-term mortality in AH, MELD seems to be the most accurate. The mortality of moderate AH is 3% to 7% in the short to medium term and 13% to 20% at 1 year, mainly because of liver-related complications, including severe infections. Long-term abstinence is the main goal of the treatment. There is still need for the development of new therapies for AH, including the less severe forms.

Coronavirus Disease 2019 Hangover: A Rising Tide of Alcohol Use Disorder and Alcohol-Associated Liver Disease

The coronavirus disease 2019 (COVID-19) pandemic has had a tremendous global impact since it began in November of 2019. However, there are concerns that the COVID-19 pandemic will not affect all equally and that some populations will be particularly vulnerable. Relevant to liver disease, patients with alcohol use disorder (AUD) and alcohol-associated liver disease (ALD) may be among the populations that are the most severely impacted. The reasons for this include being at a higher risk of severe COVID-19 infection due to a depressed immune system and high-risk underlying comorbidities, the injurious effect of COVID-19 on the liver, the inability to attend regular visits with providers, diversion of hospital resources, and social isolation leading to psychological decompensation and increased drinking or relapse. As a result, we fear that there will be a dramatic rising tide of alcohol relapse, admissions for decompensated ALD, and an increase in newly diagnosed patients with AUD/ALD post-COVID-19 pandemic. Providers and their institutions should implement preemptive strategies such as telehealth and aggressive patient outreach programs now to curb this anticipated problem. Liver transplantation (LT) centers should adapt to the pandemic by considering leniency to some LT candidates with ALD who cannot access appropriate alcohol treatment due to the current situation. In conclusion, the COVID-19 pandemic will likely be especially detrimental to patients with AUD/ALD, and actions need to be taken now to limit the scope of this anticipated problem.

Puerarin Exerts the Hepatoprotection from Chronic Alcohol-Induced Liver Injury via Inhibiting the Cyclooxygenase-2 and the 5-Lipoxygenase Pathway in Rats

BACKGROUND

Puerarin (PR) as one of the main ingredients of the root of the traditional herb Kudzu has been suggested to improve chronic alcohol-induced liver injury. We explore the specific mechanisms of PR on hepatocellular changes after administration of alcohol.

METHODS

Sprague-Dawley rats were treated with 55% alcohol for 12 weeks to induce a chronic alcoholic liver damage model. Then the rats in each group were administered by oral gavage with zileuton, celecoxib, and PR for 2 weeks, respectively.

RESULTS

In the PR group, the weight loss was markedly improved and the abnormal serum alanine aminotransferase and aspartate aminotransferase were significantly lowered after PR treatment when compared to the alcoholic liver injured model group. Pathological examination indicated that alcohol-induced hepatocellular injury was improved by the PR treatment. The 5-lipoxygenase (5-Lox) and cyclooxygenase-2 (Cox-2) at the protein level and the mRNA level were obviously downregulated accompanied with the PR treatment. Meanwhile, the peroxisome proliferator-activated receptor γ (PPAR-γ) at the protein and mRNA level was notably elevated and the tumor necrosis factor α at the protein and mRNA level was markedly decreased following the PR treatment.

CONCLUSION

The possible cytoprotective mechanisms of PR may be involved inhibition of the Cox-2 pathway and the 5-Lox pathway to suppress inflammatory response and regulate the protective factor PPAR-γ expression.

The knowns and unknowns of treatment for alcoholic hepatitis

Alcoholic hepatitis is an acute, inflammatory liver disease associated with high morbidity and mortality both in the short term and long term. Alcoholic hepatitis often arises in patients with a background of chronic liver disease and it is characterised by the rapid onset of jaundice and the development of myriad complications. Medical therapy for severe alcoholic hepatitis relies on corticosteroids, which have modest effectiveness. Abstinence from alcohol is critically important in patients with alcoholic hepatitis, but recidivism is high. Because of the absence of effective medical treatments for alcoholic hepatitis and alcohol dependency, there is a pressing need to develop new and effective therapeutics. Supported by promising preliminary and preclinical studies, many ongoing clinical trials of new therapies for alcoholic hepatitis are currently underway and are discussed further in this Series paper.

Substance Use Disorders in Recently Hospitalized Patients With Cirrhosis

OBJECTIVES

Cirrhosis is often a consequence of substance use disorders (SUD) and can lead to significant morbidity, mortality, and hospitalizations. We aimed to determine presence and impact of SUD in recently hospitalized patients with cirrhosis, which has not been previously described.

METHODS

This is a retrospective study of consecutive patients with cirrhosis seen at a post-discharge hepatology clinic. The presence of clinically-recognized SUD and documented establishment of addiction treatment, as noted in routine clinical care, was determined through medical record review. Number of hospitalizations, 30-day readmissions, and all-cause mortality at 1 year were also examined.

RESULTS

Among 99 patients, 72% were male and the median age was 55 years. The most common etiologies of cirrhosis were alcohol-related liver disease and hepatitis C infection. Alcohol use disorder was documented in 71%. Nearly all patients with clinically-recognized SUD underwent social work evaluation during hospitalization and 65% were referred to addiction treatment. Establishment of addiction care at follow up was documented in 35%. Documented SUD was associated with greater odds of hospitalization over 1 year (adjusted odds ratio 5.77, 95% confidence interval [1.36, 24.49], P = 0.017), but not with 30-day readmissions or mortality.

CONCLUSIONS

Clinically-recognized SUD was common in recently hospitalized patients with cirrhosis and associated with at least 1 other hospitalization within a year. Establishment of addiction treatment was documented in only a minority of patients. Further research is needed to determine whether patients with cirrhosis and SUD experience unique barriers to addiction treatment and if integration of SUD care in hepatology settings may be beneficial.

Therapeutic potential of PACAP in alcohol toxicity

Alcohol addiction is a worldwide concern as its detrimental effects go far beyond the addicted individual and can affect the entire family as well as the community. Considerable effort is being expended in understanding the neurobiological basis of such addiction in hope of developing effective prevention and/or intervention strategies. In addition, organ damage and neurotoxicological effects of alcohol are intensely investigated. Pharmacological approaches, so far, have only provided partial success in prevention or treatment of alcohol use disorder (AUD) including the neurotoxicological consequences of heavy drinking. Pituitary adenylate cyclase-activating polypeptide (PACAP) is an endogenous 38 amino-acid neuropeptide with demonstrated protection against neuronal injury, trauma as well as various endogenous and exogenous toxic agents including alcohol. In this mini-review, following a brief presentation of alcohol addiction and its neurotoxicity, the potential of PACAP as a therapeutic intervention in toxicological consequences of this devastating disorder is discussed.