New Diagnostic and Prognostic Models for the Development of Alcoholic Cirrhosis Based on Genetic Predisposition and Alcohol History

Liver cirrhosis development is a multifactorial process resulting from a combination of environmental and genetic factors. The aim of the study was to develop accurate non-invasive diagnostic and prognostic models for alcoholic cirrhosis. Consecutive subjects with at-risk alcohol intake were retrospectively enrolled (110 cirrhotic patients and 411 non-cirrhotics). At enrollment, the data about lifetime drinking history were collected and all patients were tested for Patatin-like phospholipase domain-containing protein 3 (PNPLA3) rs738409, Transmembrane 6 Superfamily 2 (TM6SF2) rs58542926, and hydroxysteroid 17-beta dehydrogenase 13 (HSD17B13) rs72613567 variants. In cross-sectional analyses, models for the diagnosis of cirrhosis were developed using multivariate logistic regression. A predictive score for cirrhosis development over 24 years was built by evaluating time-dependent AUC curves. The best diagnostic accuracy was demonstrated by the model, which also includes daily alcohol consumption, duration of hazardous alcohol use, and genetic variants, with AUCs of 0.951 (95% CI 0.925-0.977) and 0.887 (95% CI 0.925-0.977) for cirrhosis and compensated cirrhosis, respectively. The predictive model for future cirrhosis development (AUC of 0.836 95% CI: 0.769-0.904) accounted for age at onset of at-risk alcohol consumption and the number of PNPLA3 and HSD17B13 variant alleles. We have developed accurate genetic and alcohol consumption models for the diagnosis of alcoholic cirrhosis and the prediction of its future risk.

Alcohol withdrawal syndrome: diagnostic and therapeutic methods

Alcohol withdrawal syndrome (AWS) is a medical emergency, rare in the general population, but very common among alcoholic individuals, which can lead to severe complications when unrecognized or late treated. It represents a clinical condition which can evolve in few hours or days following an abrupt cessation or reduction of alcohol intake and is characterized by hyperactivity of the autonomic nervous system resulting in the development of typical symptoms. According to DSM-5 criteria, the alcohol withdrawal syndrome is defined as such: if patients present at least two of typical signs and symptoms. The Clinical Institute Withdrawal Assessment of Alcohol Scale, revised version (CIWA-Ar), is the tool for assessing the severity of AWS. The support to patient with AWS includes pharmacological intervention as well as general support, restoration of biochemical imbalances and specific therapy. Regarding the pharmacological treatment, benzodiazepines represent the gold standard, in particular long-acting benzodiazepines, administered with a gradual reduction up to cessation.

Treatment of alcohol use disorder from a psychological point of view

The development of a treatment for alcohol use disorder (AUD) is a crucial and complex moment. Indeed, the information gathered by a team of professionals (physicians, psychologists and social workers) (bio-psycho-social model of AUD) interact to choose the most appropriate cure. As for AUD psychological treatment, it is of considerable importance to avoid clinical treatments leading to drop-out for improving the patients quality of life. Psychoanalytic and behavioral techniques were early utilized as psychological treatment of AUD, however, evidence-based approaches as motivational interviewing (MI) and cognitive behavioral therapy (CBT) are recently used in AUD. In this work we review the more effective and appropriate AUD psychological treatments.

Pharmacological treatment of alcohol use disorder. Scientific evidence

Pharmacological treatment of alcohol use disorder represents an essential core of the therapeutic project in a multidisciplinary approach. While non-drug treatment is evolving, from a medical perspective few pharmacotherapies are available; in particular acamprosate, naltrexone and more recently nalmefene among anticraving drugs, disulfiram as an antidipsotropic medication. New studies are focusing on off-label drugs. Moreover, scientific evidence has to support any therapeutic indication which should be tailored on patient needs and comorbidity by considering the individual bio-psycho-social profile. Follow-up is essential in order to assess patient compliance to treatment and monitoring outcomes.

A two gene-based risk score predicts alcoholic cirrhosis development in males with at-risk alcohol consumption

Background

Alcoholic cirrhosis represents 1% of all cause-of-deaths worldwide. Its incidence is higher in males and results from the combination of environmental and genetic factors. Among all the genetic determinants of alcoholic cirrhosis, the patatin-like phospholipase domain protein 3 (PNPLA3) rs738409 represents the most widely validated determinant. Recent cross-sectional studies on alcohol abusers identified transmembrane-6 superfamily member 2 (TM6SF2) rs58542926, membrane bound O-acyltransferase domain containing 7 (MBOAT7) rs641738, and cluster of differentiation 14 (CD14) rs2569190 as new genetic risk factors for alcoholic cirrhosis. We aimed to develop a gene-based risk score to predict the incidence of alcoholic cirrhosis in males with at-risk alcohol consumption.

Materials and methods

A total of 416 male at-risk alcohol drinkers were retrospectively examined. The association between alcoholic cirrhosis incidence and PNPLA3, CD14, TM6SF2, and MBOAT7 variants was tested. Age at onset of at-risk alcohol consumption, age, and body mass index (BMI) were included as covariates to determine the prediction score for alcoholic cirrhosis incidence by evaluating time-dependent receiver operating characteristic curves.

Results

We found that PNPLA3, CD14, and TM6SF2 were associated with alcoholic cirrhosis prevalence. PNPLA3 and CD14 were also associated with its incidence. The best predictive score formula was (age at onset of at-risk alcohol consumption × 0.1) + (number of CD14 allele T) + (number of PNPLA3 allele M) + (BMI × 0.1). A threshold of 7.27 was identified as cutoff for the predictive risk of alcoholic cirrhosis development in 36 years from the onset of at-risk alcohol consumption with 70.1% sensitivity and 78.7% specificity.

Conclusion

We developed the first score for alcoholic cirrhosis prediction that combines clinical and genetic factors.

Pharmacological treatment for dual diagnosis: a literature update and a proposal of intervention

Background

It has long been appreciated that alcohol use disorder (AUD) is associated with increased risk of psychiatric disorder. As well, people with history of mental disorder are more likely to develop lifetime AUD. Nevertheless, the treatment of dual diagnosis (DD) in alcohol addiction still remains a challenge. The efficacy of pharmacological treatment for these patients has been widely investigated with controversial results. Patients with untreated psychiatric disorder are at higher risk to return to drinking and tend to do so more quickly. The aim of this review was to collect clinical data for developing guidelines for the pharmacological treatment of psychiatric diseases in a population with AUD.

Materials and methods

A literature review was conducted using the following databases: PubMed-NCBI, Cochrane database, Embase Web of Science, and Scopus, including studies published between 1980 and 2015. Search terms were: “guideline”, “treatment”, “comorbidity”, “substance abuse”, “alcohol”, “dual-diagnosis”, “antidepressant”, “antipsychotic”, “mood-stabilizer”. Out of 1521 titles, 84 studies were included for their relevance on pharmacological treatment of psychiatric disorders in people with AUD.

Results

Different drugs were collected in major pharmacological classes (antidepressant, mood-stabilizer, antipsychotic), in order to identify their proved efficacy for treating specific psychiatric disorder in the AUD population. Data were selected and verified for publications from randomized clinical trials, open-label trials and case reports.

Conclusions

DD in alcohol dependence is a complex clinical entity, and its high prevalence is supported by epidemiological data. Pharmacological management of psychiatric disorders in patients with AUD remains partially anecdotal. Based on reviewed articles, we propose a classification of psychiatric medications for treatment of mental disorders comorbid with AUD, listed with evidence-based recommendations. More research is needed to obtain and collect clinical data, in order to organize and share evidence-based guidelines.

Drafting a dual diagnosis program: a tailored intervention for patients with complex clinical needs

Background

Clinical practice of mental health services changed in 1978 after the Basaglia Law was passed, and it is now characterized by usually voluntary treatments offered by community-based services. That broadened the interventions’ focus from the single subject to their environment. Dual diagnosis is defined by WHO as «the co-occurrence in the same individual of a psychoactive substance use disorder and another psychiatric disorder». It is considered to be a “border territory” since entails networking between different medical services.

Materials and methods

A literature search was performed in PubMed, Web of Science, Scopus and Google Scholar. Search terms were: “guidelines”, “treatment”, “comorbidity”, “substance abuse”, “alcohol”, “dual-diagnosis”, “psychiatric illness”, “outpatient”, “inpatient”, “health care service”, “clinical practice”. National and regional regulations about health and addiction were screened too. Out of 598 titles, 31 studies were included in this article for their relevance on treatments and networking between services for dual diagnosis cases.

Results

There are not any guidelines for clinical practice in the literature, neither there are any shared treatment strategies on a national level. Considering the autonomy that every regional health service has, several different courses of action are possible. Here there are reported the ones available.

Conclusions

After discussing the weak points of the treatment options, we suggest the “Multidisciplinary Healthcare” model to best address the difficulties represented by dual diagnosis cases.

The multidisciplinary support in preventing alcohol relapse after liver transplantation: A single-center experience

BACKGROUND AND AIM

Alcoholic liver disease (ALD) represents a frequent indication for liver transplantation (LT). Since 2004, we have adopted a program of multidisciplinary support(MS) to assist patients undergoing LT for ALD. We aimed at analyzing the relapse rate and the risk factors for relapse. The relapse rate was also compared with that of a historical group of patients who underwent transplantation. Their survival rate was also analyzed.

PATIENTS AND METHODS

Consecutive patients with ALD transplanted from 2004 were included. The most important demographic, psychosocial, and clinical characteristics known to be associated with alcohol relapse were recorded.

RESULTS

Sixty-nine patients underwent MS: 8.7% presented alcohol relapse. At multivariate analysis female gender (sHR 9.02, 95% CI 1.71-47.56, P = .009), alcohol withdrawal syndrome (sHR 5.89, 95% CI 1.42-24.46, P = .015) and a shorter time of MS program before LT (sHR 0.928 per month, 95% CI 0.870-0.988, P = .021) were identified as independent risk factors for relapse. The rate of alcohol relapse was significantly lower than that of the historical group who did not undergo MS (sHR 0.21, 95% CI: 0.06-0.68; P = .009).

CONCLUSION

This study shows that a MS program may contribute to alcohol relapse prevention after LT in ALD patients. However, the relevance of this support needs to be confirmed by clinical trials.

PNPLA3 I148M (rs738409) genetic variant and age at onset of at-risk alcohol consumption are independent risk factors for alcoholic cirrhosis

BACKGROUND & AIMS

Environmental and genetic factors contribute to alcoholic cirrhosis onset. In particular, age at exposure to liver stressors has been shown to be important in progression to fibrosis in hepatitis C individuals. However, no definite data on the role of age at onset of at-risk alcohol consumption are available. Moreover, patatin-like phospholipase domain-containing protein 3 (PNPLA3) I148M (rs738409) variant has been associated with alcoholic cirrhosis, but only in cross-sectional studies. The aim of this study was to investigate the role of age at onset of at-risk alcohol consumption and PNPLA3 I148M variant on alcoholic cirrhosis incidence.

METHODS

A total of 384 at-risk alcohol drinkers were retrospectively examined. The association among age at onset of at-risk alcohol consumption, PNPLA3 I148M variant and cirrhosis incidence was tested.

RESULTS

A higher incidence of alcoholic cirrhosis was observed in individuals with an older (≥24 years) compared with a younger (<24) age at onset of at-risk alcohol consumption (P-value < 0.001). Moreover, PNPLA3 148M allele carriers showed an increased incidence of cirrhosis (P-value < 0.001). Both age at onset of at-risk alcohol consumption and PNPLA3 148M allele were independent risk factors for developing cirrhosis (H.R. (95% C.I.): 2.76 (2.18-3.50), P-value < 0.001; 1.53(1.07-2.19), P-value = 0.021 respectively). The 148M allele was associated with a two-fold increased risk of cirrhosis in individuals with a younger compared with an older age at onset of at-risk alcohol consumption (H.R. (95% C.I.): 3.03(1.53-6.00) vs. 1.61(1.09-2.38).

CONCLUSIONS

Age at onset of at-risk alcohol consumption and PNPLA3 I148M genetic variant are independently associated with alcoholic cirrhosis incidence.

Lansoprazole-induced microscopic colitis: an increasing problem? Results of a prospecive case-series and systematic review of the literature

BACKGROUND

Microscopic colitis (MC), comprising lymphocytic and collagenous colitis (LC, CC), causes chronic diarrhoea. Lansoprazole can cause MC. Likelihood criteria defining the causative relationship between drugs and MC have not been applied to lansoprazole, nor has lansoprazole-related-MC been characterized.

AIM

To analyse a series of lansoprazole-related MC cases, and characterize lansoprazole-related CC and LC.

METHODS

Cases were diagnosed over 23 months and causal relationship evaluated by established likelihood criteria. A systematic Medline search was conducted and publications analysed.

RESULTS

Eight patients had lansoprazole-related MC. In all cases chronological and causality likelihood scores supported lansoprazole causative role. Discontinuation determined resolution without further treatment. Twenty-five cases of lansoprazole-related MC from 10 publications were grouped with the present series, and differences between CC and LC analysed. CC cases had more macroscopic alterations at colonoscopy (72.2 vs. 6.6%; p=0.0002). Time between lansoprazole start and symptoms onset was longer for CC (median 60 vs. 28 days; p=0.03).

CONCLUSIONS

Peculiar features of lansoprazole-related CC were described through the analysis of a newly diagnosed lansoprazole-related MC series in which the causative role of lansoprazole was for the first time defined by established likelihood criteria, and by pooled evaluation with other cases retrieved by a systematic literature review.

Acute alcoholic hepatitis

Acute alcoholic hepatitis (AAH) is a frequent inflammatory liver disease with high short-term mortality rate. In this review, relationships between alcohol abuse and the epidemiology and the outcomes of AAH are discussed, as well as AAH pathogenesis. The role of endotoxins, tumor necrosis factor alpha, fibroblasts, and immune response to altered hepatocyte proteins is discussed. The need of a careful prognosis, supported by the use of Maddrey score, by the model for end-stage liver disease [Mayo end-stage liver disease (MELD)] score or by the Glasgow alcoholic hepatitis score, is outlined, as the use of the most effective drugs (glucocorticoids and anti-tumor necrosis factor alpha infliximab) is recommended only in severe AAH cases. The problems of liver transplant in severe AAH, and the need of a 6-month alcohol abstinence before transplant, are discussed, as well as the need of a careful psychologic assessment before the transplant.

ERYTHROCYTE THIAMINE (Th) ESTERS: A MAJOR FACTOR OF THE ALCOHOL WITHDRAWAL SYNDROME OR A CANDIDATE MARKER FOR ALCOHOLISM ITSELF?

AIMS

Thiamine (Th) deficiency is a major problem in alcoholics. In this study, the relationship of alcohol withdrawal syndrome (AWS) to Th and its esters, as well as the diagnostic power of Th and its esters were investigated.

PATIENTS AND METHODS

Th and its esters were assessed in a series of chronic alcoholics (and in controls) using an improved method.

RESULTS

No association was found between AWS severity and Th and its esters, while the diagnostic power of thiamine diphosphate (TDP) and Th was very high. TDP was the most significant among the parameters under study, confirming that erythrocyte TDP is a suitable marker of alcoholism: TDP sensitivity across subjects was 84.1%, specificity 85.4%, positive predictive value 82.4%, and negative predictive value 88.0%.