Out With the Old, in With the New: Replacing the "6-Month Abstinence Rule" With Integrated Care for Alcohol-Associated Liver Disease

The impact of liver transplantation on endpoint selection in alcohol-associated hepatitis trials

BACKGROUND

Alcohol-associated hepatitis (AH) is a serious liver disease caused by heavy alcohol consumption with severe cases exhibiting a 90-day mortality rate of ~30%. No drugs have been approved for AH, and regulatory approval currently requires evidence of improved survival. The lack of effective drug therapies and high mortality rates have fueled interest in early liver transplantation (LT), which has a survival rate that exceeds 90%. However, LT is resource-intensive and is available only in expert centers, where most AH trials are conducted. As a result, LT is overrepresented in recent AH studies, leading to confounding and unresolved questions regarding valid endpoints in therapeutic AH trials.

METHODS

We propose methodological approaches to address the inclusion of LT in AH trials, supported by power calculations and data from the AHFIRM trial, a 300-patient multicenter study completed in late 2023. We demonstrate the impact of effect size, trial size, and statistical methods on trial design and interpretation.

RESULTS

Effect size plays a crucial role in power calculations. While 90-day survival is the most efficient endpoint, competing risk analysis, primary stratum analysis, and win ratio are valuable tests for assessing the role of LT. The combined endpoint of death or LT is the least efficient method and requires the largest trial population to achieve statistical significance. We recommend using multiple statistical methods with adjustments for multiplicity.

CONCLUSIONS

The adoption of early LT complicates the assessment of new therapies for AH. Statistical methods and endpoints are critical in power calculations and when assessing the efficacy of new therapeutic agents. We recommend mortality as the primary analysis complemented by hierarchical secondary analyses that avoid problems of multiplicity.

Integrated and collaborative care across the spectrum of alcohol-associated liver disease and alcohol use disorder

The public health impact of alcohol-associated liver disease (ALD), a serious consequence of problematic alcohol use, and alcohol use disorder (AUD) is growing, with ALD becoming a major cause of alcohol-associated death overall and the leading indication for liver transplantation in the United States. Comprehensive care for ALD often requires treatment of AUD. Although there is a growing body of evidence showing that AUD treatment is associated with reductions in liver-related morbidity and mortality, only a minority of patients with ALD and AUD receive this care. Integrated and collaborative models that streamline both ALD and AUD care for patients with ALD and AUD are promising approaches to bridge this treatment gap and rely on multidisciplinary and interprofessional teams and partnerships. Here, we review the role of AUD care in ALD treatment, the effects of AUD treatment on liver-related outcomes, the impact of comorbid conditions such as other substance use disorders, obesity, and metabolic syndrome, and the current landscape of integrated and collaborative care for ALD and AUD in various treatment settings. We further review knowledge gaps and unmet needs that remain, including the role of precision medicine, the application of harm reduction approaches, the impact of health disparities, and the need for additional AUD treatment options, as well as further efforts to support implementation and dissemination.

The stigma of alcohol-related liver disease and its impact on healthcare

People with alcohol-related liver disease (ALD) experience stigma and discrimination. This review summarises the evidence on stigma in healthcare and its implications for people with ALD, drawing from the literature on the stigma associated with mental illness and, specifically, alcohol use disorder (AUD). Public stigma, self-stigma and structural stigma all contribute to failure to seek help or delays in seeking help, inferior healthcare, and negative health outcomes, which increase the overall burden of ALD. Stigma can be experienced, but also anticipated and avoided, with both scenarios negatively impacting on ALD healthcare. Blaming people with ALD for their condition is central to the stigma of ALD. Stigma affects ALD healthcare at all stages, from prevention, early detection and intervention, to allocation of scarce resources in liver transplantation. People with lived experience need to be empowered to lead action against the stigmatisation of patients with ALD. Promulgating a dynamic model of individual and social responsibility for AUD, a continuum model of harmful alcohol use, and establishing training on ALD-related stigma for healthcare professionals are strategies to address stigma. Integrating addiction and ALD services, providing stigma-free prevention, and overcoming the frequent separation of addiction services from general healthcare are necessary. Beyond healthcare, addressing social inequality, the social dimensions of ALD risk and outcomes, and ensuring equal access to services is necessary to improve outcomes for all people with ALD. More research is needed on the stigma of ALD in low- and middle-income countries and in countries with restrictive drinking norms. Interventions to reduce the stigma of ALD and facilitate early help-seeking need to be developed and evaluated.