Early intervention critical, before ‘significant clinical toll’ from excessive alcohol use
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Alcohol use disorder has a huge impact on liver health. Regardless of whether patients have other primary etiology for liver disease, alcohol — even in minimal amounts — can worsen liver outcomes.
In 2011, hepatitis C virus infection was the most common indication for liver transplantation, accounting for nearly 25% of all transplants done in the U.S. However, since the advent of highly effective direct acting antivirals, HCV as the primary indication for LT dropped to 5% in 2021. Instead, alcohol-associated liver disease (ALD) has quickly become the dominant reason for patients needing LT, accounting for nearly 40% of all transplants in 2021.
This dramatic increase in ALD morbidity is the result of a precipitous rise in harmful alcohol intake. The COVID-19 pandemic exacerbated this trend, with rates of harmful alcohol intake increasing, especially in younger patients aged 25 to 44 years. In 2022, the CDC found that excessive alcohol use disorder (AUD) accounted for more than 140,000 deaths in the U.S., shortening lives on average of 26 years.
As a transplant hepatologist, my clinical focus generally falls to liver-related morbidity and mortality from excessive alcohol use. However, we know that excessive alcohol consumption is associated with other severe clinical diseases, including acute and chronic pancreatitis and esophageal, stomach, pancreatic and colorectal cancers that general gastroenterologists come across every day.
Excessive alcohol intake is generally defined as eight or more drinks per week for women and 15 or more drinks per week for men, and these individuals are at risk for alcohol-related morbidity and mortality. Identifying and intervening before the development of advanced alcohol-associated medical issues will be helpful.
There are far and away more general GIs in practice in the U.S. than those who practice primarily hepatology. General GIs may also encounter patients earlier in the course of alcohol-associated diseases. By the time patients reach a hepatologist, excessive alcohol use may have already taken a significant clinical toll on the patient. Intervening earlier to address potentially harmful drinking can hopefully prevent patients from ever needing a hepatologist.
It is critical for hepatologists to partner with GIs. When a patient, for example, has reflux disease, GIs can screen them for AUD and can determine the patient’s risk factors for progressing to other chronic problems, as a result of their AUD.
Therefore, intervening before a patient needs a hepatologist or transplant hepatologist is always going to be more beneficial for our patients than trying to catch it at the tail end when their AUD has already made a significant impact on their health.
- References:
- Abbas D, et al. Clin Ther. 2023;doi:10.1016/j.clinthera.2023.08.018.
- Alcohol use and your health. https://www.cdc.gov/alcohol/fact-sheets/alcohol-use.htm. Accessed Jan. 17, 2024.
- Excessive alcohol use. https://www.cdc.gov/chronicdisease/resources/publications/factsheets/alcohol.htm. Accessed Jan. 17, 2024.
- Kwong AJ, et al. Am J Transplant. 2023;doi: 10.1016/j.ajt.2023.02.006.
- White AM, et al. JAMA. 2022;doi:10.1001/jama.2022.4308.
- For more information:
- Brian Kim, MD, is a transplant hepatologist and associate professor of clinical medicine at Keck Medicine of the University of Southern California. He can be reached at brian.kim2@med.usc.edu.
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