Surge in alcohol-related disease during pandemic reveals unmet need for treatment
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Alcohol-related deaths have climbed steadily over the past two decades, and with the onset of the COVID-19 pandemic, alcohol-associated disease and mortality rates have continued to soar.
“It is clear that there has been an increase in hospitalizations for alcohol-associated hepatitis, at least at large tertiary centers,” Douglas Simonetto, MD, associate professor of medicine and director of gastroenterology and hepatology fellowship program at the Mayo Clinic in Minnesota, said, noting an increase in alcohol-associated hepatitis particularly among young adults and women in his practice. “There are a few studies already published showing this trend, and we are seeing the same here in Rochester.”
According to a study by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), there was a 25% increase in alcohol-related deaths between 2019 and 2020 — the first year of the pandemic — and a 22.4% increase in alcohol-related liver disease. Another study published in Alcohol and Alcoholism cited psychosocial stressors, such as social isolation, dissolution of structured endeavors and unemployment, as triggers for dangerous alcohol consumption during this time. Researchers warned there may be a surge in alcohol liver disease-related complications far beyond the pandemic.
Just last year, research presented at The Liver Meeting Digital Experience detailed an 81% increase in alcohol-associated hepatitis admissions within the first year of the pandemic, resulting in a significant rise in liver transplantation; 39% of those admissions cited a pandemic-related factor for alcohol use.
To better understand this alarming trend, Healio Gastroenterology spoke with Simonetto and other leading experts about the impact COVID-19 has had on alcohol use and the rise in alcohol-associated hepatitis and LT as a result of harmful levels of alcohol consumption.
Candidates for Liver Transplant
According to Simonetto, the standard 6-month rule, which suggests that patients with alcohol-associated hepatitis abstain from drinking for 6 months before being considered for an LT, is obsolete. Although many transplant centers still follow this rule, it is not the current guidance.
“Most patients with severe alcohol-associated hepatitis who do not respond to medical therapy do not survive 6 months,” Simonetto said. “Mortality is about 70% to 80% at 6 months in these patients, so if we wait that long we’ll lose majority of patients.”
Further, he said, alcohol relapse after LT should not be considered a measured outcome for post-transplant success. Instead, the focus should be achieving sustained abstinence, improvement of quality of life and survival and that patients should be considered for transplant, despite the high possibility of relapse.
Rather than trying to determine whether a patient is an acceptable candidate for transplant based solely on risk for relapse, Simonetto noted that physicians should consider ways to support patients after LT. “It’s important to know their risk for drinking, or return to drinking, after transplant,” Simonetto said, “not to preclude them from being transplant candidates, but to allocate the resources necessary to prevent them from relapsing or, if they do relapse, to return to sustained sobriety.”
![Hospitalizations for alcohol-associated hepatitis soared during COVID-19, noted Raymond Chung, MD, worsened by a lack of effective therapies. “This [population problem] needs to have continued heightened attention.”](/~/media/images/news/print/healio-gastroenterology/2022/05_may/chung_raymond_1200x630.jpg)
Source: Raymond Chung, MD.
According to Andrew J. Muir, MD, professor of medicine and chief of gastroenterology at Duke University, there is currently debate about when LT is appropriate in patients with alcohol-associated liver disease. “Many programs traditionally had a very hard line around 6 months of sobriety,” he said. “However, more programs are getting away from such numbers. ... It’s a very complicated process to understand whether or not the patient will do well after transplant, not only physically but also from the standpoint of their addiction. It’s an area that is evolving.”
Ashwani K. Singal, MD, MS, FACG, transplant hepatologist and professor of medicine at the University of South Dakota, considers LT when a patient has a severe and progressive disease, which is not improving, despite optimal medical treatment for 3 to 7 days. “When selecting this population, which I think is muddy in terms of selection criteria, we want to select a patient who is least likely to engage in alcohol use after transplant,” he said. “Clearly, psychosocial eligibility takes priority over medical eligibility. Detailed input from a multidisciplinary team, including an addiction counselor and social worker can characterize the risk of relapse after transplant.”
Physicians also should determine whether patients have psychiatric drivers or environmental stressors underlying their behaviors and assess adequacy of social supports, said Raymond Chung, MD, director of hepatology and the Liver Center at Massachusetts General Hospital and professor of medicine at Harvard Medical School, emphasizing the importance of evaluations by specialists, including psychiatrists, social workers and addiction counselors.
“It’s been very gratifying that we’ve been able to offer a second shot at life for these patients,” Chung said, noting that 5 or 6 years ago patients with alcohol-associated hepatitis were not even considered for LT. “Looking at some of our patients in the pandemic period who were transplanted for AAH — and we’ve had a substantial number of such patients — we’ve seen that the great majority have not reverted to drinking, which is very encouraging. With appropriate counseling and social support and just having the new lease on life, many managed to modify the behavior, even as the pandemic has persisted.”
Guidance and Care for Patients
According to the NIAAA, adults of legal drinking age can choose not to drink or to drink in moderation by limiting intake to two drinks or less a day for men and one drink or less a day for women. All experts agreed that patients should be made aware of these guidelines.
“Patients may not even be aware of liver disease,” Chung said, stressing that patients with ongoing chronic liver disease should avoid alcohol. “This is not just up to us but really to primary care providers, who come into contact with folks before they get sick. It’s important to really drill down on the quantity, because once the threshold gets exceeded, it’s then that people get into trouble.”
Muir added that physicians should feel comfortable talking to their patients about alcohol use, and that patients tend to answer questions more directly this way. He references the recommended amount of alcohol use or low-risk drinking guidelines from the NIAAA, so patients will understand a safe amount of drinking.
Hepatologists need to be trained on how to discuss not only alcohol use but also medications for psychosocial issues, insomnia, anxiety or depression, Singal said, noting that physicians should feel comfortable prescribing these medications and discussing addiction with patients. “Most hepatologists lack training on managing alcohol-use disorder,” he said. “It’s not only a behavior; it is a disease.”
In 2020, Singal and colleagues published survey results in Clinical Gastroenterology and Hepatology, which revealed that of more than 400 gastroenterologists and hepatologists who submitted responses, 77% reported limited addiction education and 90% desired more education during GI/hepatology fellowship training.
Albert Do, MD, MPH, assistant professor and clinical director of the Fatty Liver Disease Program at Yale School of Medicine, said, “Providers should be considering unhealthy alcohol use among all patients and consider instituting an approach for routine screening, to identify patients who might be engaging in unhealthy use. In those who report increased use, addressing underlying patient concerns or causes should be considered, as those issues might be remediable.”
When caring for patients with alcohol-associated hepatitis, physicians need to be “intentional” when offering resources to help them stop using alcohol, Simonetto said. “It is important to acknowledge that alcohol-use disorder is a disease, and it needs to be treated as such,” he said. “It is not a behavior; it is not a choice — we need to be framing it that way to patients, so they understand that they need help, and then provide them with appropriate resources to successfully quit drinking. Simply asking them to quit alcohol use, as if they could do that easily on their own, is not effective or fair to patients.”
In a study published in Clinical Gastroenterology and Hepatology, Simonetto and colleagues demonstrated that referring patients to early-alcohol rehabilitation within 30 days of hospital discharge reduced the risk for readmission, relapse and death. They conducted a retrospective analysis of 135 patients with alcohol-associated hepatitis between 1999 and 2016 (test cohort) and an external cohort of 159 patients in a multicenter alcohol-associated hepatitis research consortium (validation cohort).
According to study results, 27 patients in the test cohort attended early-alcohol rehabilitation compared with 19 patients in the validation cohort. The 30-day readmission rate in both cohorts was 30%, and the relapse rate was 37% in the test cohort and 34% in the validation cohort. There were 53 deaths in a median follow-up time of 2.8 years in the test cohort and 42 deaths in a median follow-up time of 1.3 years in the validation cohort.
“We need to be more intentional and aggressive at getting these patients adequate psychiatric care, and engaging them in sober support groups, like Alcoholics Anonymous,” Simonetto said. “It is part of our job as hepatologists to help patients get the resources they need to quit.”
Muir added, “We don’t have adequate mental health support for patients. So many of these people are drinking alcohol to self-medicate, and we need better support for people who are struggling with substance abuse and addiction. People are struggling with addiction, and, in other ways, people are struggling with anxiety. All those things are highlighting for me that we really need better mental health services in our society.”
Chung noted that in addition to professional rehabilitation and care, there are online communities, such as Moderation Management, and even digital applications that can help individuals cut back on or cut out drinking.
“Once you’ve identified that somebody has a problem drinking, I think helping them cut down on their drinking and referring them to addiction specialists would be an important point,” Chung said. “But even for those who may not actually necessarily meet criteria for addictive drinking, I think that there are certainly ways they could begin to cut back on their drinking.”
Limited Treatment Options
According to Chung, treatment is limited for patients with alcohol-associated hepatitis. Although short-term corticosteroids are an option, contraindications exist.
“These patients are all very sick, and they may be at risk for GI bleeding or infection,” he said. “Those are two strong reasons not to give corticosteroids.
“We have found no other agents that we’re aware of that can actually improve short-term mortality in [alcohol-associated hepatitis], let alone long-term mortality.”
However, with so few options available, prednisone (or prednisolone) is still a consideration, and there are several published studies that show it can improve survival in severe cases of disease.
“Although that benefit might be marginal, it is the only drug that we have that may improve survival, at least short-term survival,” Simonetto said. “Beyond 30 days, prednisone does not improve outcomes.”
According to Do, pentoxifylline is an alternative for those with contraindications to steroids, but its use is controversial due to inconsistent data. Other treatments, including N-acetylcysteine and granulocyte colony-stimulating factor, are being explored but are not routinely used.
“Aggressive nutritional support, particularly sufficient protein intake in those with known liver disease, as well as supplementation in those with acute alcohol-associated hepatitis, are likely underutilized in the health care setting,” Do said. “This is important, as it likely affects patient outcomes from this disease.”
Unfortunately, with so little to offer patients with alcohol-associated hepatitis, Chung said, there remains a large, unmet need.
“This is a population problem — one that needs to have continued heightened attention.”
- References:
- Alcohol-associated hepatitis admission ‘dramatically’ increased in first year of COVID. www.healio.com/news/hepatology/20211113/alcoholassociated-hepatitis-admission-dramatically-increased-in-first-year-of-covid. Published Nov. 13, 2021.
- Arab JP, et al. J Hepatol. 2021;doi:10.1016/j.jhep.2021.06.019.
- Drinking patterns and their definitions. https://arcr.niaaa.nih.gov/binge-drinking-predictors-patterns-and-consequences/drinking-patterns-and-their-definitions. Published Jan. 1, 2018. Accessed April 7, 2022.
- Grinspoon R, et al. Abstract 40. Presented at: The Liver Meeting Digital Experience; Nov. 12-15, 2021 (virtual meeting).
- Im GY, et al. Clin Gastroenterol Hepatol. 2020;doi:10.1016/j.cgh.2020.10.026.
- Knopf A. Alcoholism and Drug Abuse Weekly. 2022;doi:10.1002/adaw.33385.
- Peeraphatdit T, et al. Clin Gastroenterol Hepatol. 2019;doi:10.1016/j.cgh.2019.04.048.
- Singal AK, et al. JAMA. 2021;doi:10.1001/jama.2021.7683.
Collapse
Alcohol-associated hepatitis admission ‘dramatically’ increased in first year of COVID. www.healio.com/news/hepatology/
20211113/alcoholassociated-hepatitis-admission-dramatically-increased-in-first-year-of-covid. Published Nov. 13, 2021.
Arab JP, et al. J Hepatol. 2021;doi:10.1016/j.jhep.2021.06.019. Drinking patterns and their definitions. https://arcr.niaaa.nih.gov/binge-drinking-predictors-patterns-and-consequences/drinking-patterns-and-their-definitions. Published Jan. 1, 2018. Accessed April 7, 2022.
Grinspoon R, et al. Abstract 40. Presented at: The Liver Meeting Digital Experience; Nov. 12-15, 2021 (virtual meeting).
Im GY, et al. Clin Gastroenterol Hepatol. 2020;doi:10.1016/j.cgh.2020.10.026.
Knopf A. Alcoholism and Drug Abuse Weekly. 2022;doi:10.1002/adaw.33385.
Peeraphatdit T, et al. Clin Gastroenterol Hepatol. 2019;doi:10.1016/j.cgh.2019.04.048.
Singal AK, et al. JAMA. 2021;doi:10.1001/jama.2021.7683.
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