ACG publishes new guideline for management of alcohol-associated liver disease
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Key takeaways:
- Alcohol consumption should be avoided in individuals with underlying obesity or chronic HCV and HBV infection.
- A multidisciplinary care model should include behavioral interventions and/or pharmacotherapy.
A new clinical guideline published in the American Journal of Gastroenterology underscored the need to overcome barriers to alcohol use disorder treatment and expand multidisciplinary care for patients with alcohol-associated liver disease.
“I think the most important reason why the American College of Gastroenterology wanted to revise this guideline is there has been impetus and recognition that control of the risk factor of alcohol use disorder seems to be the way forward in managing and controlling the magnitude and burden of this disease,” Ashwani K. Singal, MD, MS, FACG, FAASLD, AGAF, guideline author and professor of medicine at the University of Louisville, told Healio. “The second reason is that we wanted to bring out a stronger recommendation to consider early liver transplantation in these patients.”
Singal continued: “Further, although there are no currently approved pharmacological therapies for alcohol-associated liver disease and alcohol-associated hepatitis, there are promising therapies on the horizon with a potential in the management of these patients.”
To develop a practice guideline for the management of patients with alcohol-associated liver disease (ALD), ACG experts performed a Grading of Recommendations, Assessment, Development and Evaluation analysis of data based on a patient-intervention-comparison-outcome format.
The analysis resulted in 35 key concepts or statements and 22 recommendations, which include the following.
- Alcohol consumption should be avoided among those with underlying obesity or chronic hepatitis C and hepatitis B virus infection. Those undergoing or with a history of gastric bypass should avoid heavy alcohol use.
- Given the associated higher risk for cirrhosis, heavy alcohol users should abstain from any tobacco use.
- Adults with suspected unhealthy alcohol use should undergo screening with tools such as the Alcohol Use Disorders Identification Test-Consumption tool.
- Among those with compensated ALD and alcohol use disorder (AUD), baclofen is recommended and other treatment options include acamprosate, naltrexone, gabapentin or topiramate. Experts suggest against use of disulfiram for treatment of AUD along any spectrum of ALD.
- Pentoxifylline should not be used in those with severe alcohol-associated hepatitis (AH), nor should universal administration of prophylactic antibiotics be used in hospitalized patients. Conversely, corticosteroid therapy and adjuvant IV N-acetylcysteine is recommended for those with severe AH.
- Patients with severe AH and high risk for death who are unresponsive to medical management may undergo early liver transplantation according to regional and institutional protocols.
- Integrated multidisciplinary care models that incorporate behavioral interventions and/or pharmacotherapy should be offered for those with ALD and AUD.
“What gastroenterologists and hepatologists need to recognize is to not only screen these patients for alcohol use disorder but also treat them effectively,” Singal said. “Because these patients have liver disease from alcohol use, they’re struggling not only from liver disease and their complications, but also from another disease of alcohol use disorder. We need to take a multidisciplinary integrated care approach for these patients where patients are seen not only by a liver doctor but also comprehensively by an addiction expert, including a counselor, social worker and psychiatrist.”
Singal continued: “Comprehensive holistic approach by both specialists overcomes several barriers to receiving care for alcohol use disorder, with a potential for improving long-term outcomes. Integrated approach is also recommended to design future clinical trials for drug development with evaluation of outcomes targeted at liver disease as well as on alcohol use.”
Perspective
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Shreya Sengupta, MD
The new ACG guidelines highlight key concepts for management of patients with ALD. The recommendations are categorized based on epidemiology, risk factors, diagnosis and management, and policy and prevention.
The guidelines highlight the need for nonpharmacologic and pharmacologic therapies for AUD, including various behavioral therapy techniques and medications such as baclofen, acamprosate and naltrexone.
The authors emphasize the need to refer patients for liver transplantation when appropriate, as medical providers would for patients with liver disease of any other cause, as well as the need for standardized approaches to assess a patient’s psychosocial candidacy for LT.
The ACG guidelines focus on management of alcohol use as well as liver disease and promote a more holistic approach to treating ALD than previous guidelines.
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