‘Downstream effects’ of alcohol use disorder swell in wake of COVID-19
Click Here to Manage Email Alerts
VANCOUVER, British Columbia — With alcohol-related disease still on the rise after surging during the COVID-19 pandemic, an expert here discussed treatment options, including liver transplantation, for patients with alcoholic hepatitis.
“You have to realize alcoholic liver disease, especially alcoholic hepatitis, is increasing,” Stanley M. Cohen, MD, FACG, professor of medicine and medical director of hepatology at Case Western Reserve School of Medicine, said during his presentation at the ACG Annual Scientific Meeting. “Keep it in your mind as part of your history.”
Image: Adobe Stock
Cohen attributed the recent jump in alcoholic hepatitis — and subsequent mortality — to a rise in drinking among younger individuals, specifically women aged 25 to 34 years, and the impact of COVID-19.
Citing the Explorys database study, which grouped individuals in pre-COVID and COVID cohorts, Cohen noted that findings should be of “no surprise to anybody here.”
“What we saw with regard to alcoholic liver disease was almost three times increased risk of alcoholic hepatitis,” he said. “We saw varices, alcoholic pancreatitis. So bottom line, we’re not just seeing more alcohol — we’re seeing more downstream effects.”
According to Cohen, alcoholic hepatitis is a specific syndrome with mortality ranging from 35% to 45% in 1 month. “We see it commonly in hospitalized patients with alcoholic liver disease,” he said. “They’re usually hospitalized because of alcoholic hepatitis, and most of them have cirrhosis by the time we see them.”
In addition to clinical indicators, Cohen noted that Maddrey discriminant function or MELD are the most commonly used prognostic scores, with Maddrey over 32 and MELD higher than 20 indicative of severe alcoholic hepatitis.
“Why do we care? Because that’s the group that we’re going to use therapy on and again probably steroids. Also, it translates to about a 20% 90-day mortality,” he said.
Cohen reviewed options for treatment, although many are unsuccessful, including absolute alcohol abstinence, nutritional therapy, corticosteroids and LT.
Although other treatments such as pentoxifylline have been studied, Cohen said corticosteroids remain the first-line treatment in patients with no contraindications. When treating with steroids, he recommended using Lille score to gauge effect.
“It allows us to look at them on day 0 and day 7 of steroids and we see if they’re having a response,” he said. “What we’re going to look for is a Lille score of less than 0.45: Less than 0.45, the survival is dramatically better. If it’s greater than 0.45, it’s essentially futility and we stop the steroids.”
Cohen also noted that IV N-acetylcysteine can be used as an adjunct to steroids, and that granulocyte-colony stimulating factor warrants further study.
Lastly, Cohen discussed how LT may be considered in a select group of patients, noting that the traditional 6-month sobriety rule has “no scientific basis.”
“We’re starting to see a paradigm shift that we can now evaluate people with a psychologist or a social worker,” he said. “We can really get an idea of who’s at higher risk for recidivism, who isn’t and who would be good candidate.”
Cohen highlighted a 2011 French study, which showed that a very select group of patients — without previous alcoholic liver disease, among other factors — underwent transplant for alcoholic hepatitis and had a 6-month survival of 77%; only 10% resumed drinking alcohol afterward. In a U.S. study of 147 similarly chosen patients, the 3-year survival was 84%.
One predictor to consider is the Sustained Alcohol use after Liver Transplant (SALT) score, which “basically looks at the amount of alcohol, how many failed prior rehabs, any legal issues, and if [a patient’s] score was less than five, they had a 95% negative predictive value for sustained alcohol use after transplant,” Cohen said.
“I don’t want you leaving thinking transplant is great for all these patients, but there is a subset that you want to think about,” he added.
Collapse
Cohen SM. Updates in the treatment approach for alcohol-associated hepatitis (AAH). Presented at: ACG Annual Scientific Meeting; Oct. 20-25, 2023; Vancouver, British Columbia (hybrid meeting).
Read more about
Click Here to Manage Email Alerts