Treatment of Alcohol Use Disorder and Alcohol-Associated Liver Disease

Educational Objectives

The goal of this program is to improve management of alcohol use disorder and alcohol-associated liver disease (ALD). After hearing and assimilating this program, the clinician will be better able to:

1. Reduce mortality among patients with alcohol-associated hepatitis and ALD.
2. Analyze evidence-based data regarding impacts of timed liver transplantation on abstinence from alcohol.

Summary

Diaz et al (2024): highlighted the impact of public health policies on alcohol consumption and alcohol-associated liver disease (ALD) and evaluated the impact of policies on related outcomes through an "alcohol preparedness index”, which scores the intensity of alcohol policies; countries with higher index scores (and thus more intense policies) demonstrated reductions in ALD mortality, cancer deaths, cardiovascular mortality, and hepatocellular carcinoma mortality

Idalsoaga et al (2024): demonstrated a 6-mo survival rate of 87% among patients with moderate alcohol-associated hepatitis (AH), with mortality due to preventable causes (eg, bleeding, infection); multivariate analysis identified age and infection as significant factors influencing mortality in moderate AH

Caring for Patients with Acute AH Undergoing Transplantation Evaluation

Penn Medicine Total Recovery: a 12-wk intensive outpatient program for patients with alcohol use disorder (AUD) who have undergone or are awaiting liver transplantation (LT); the program involves several hours of outpatient sessions multiple days a week without overnight stays and integrates 12-step facilitation, motivational interviewing, and cognitive-behavioral therapy

Integrated liver engagement and recovery network (I-LEARN): a multidisciplinary clinic which provides integrated ALD treatment for patients throughout the LT process; treatment is kept in-house to ensure continuous support and better preparation

Results of the programs: Penn Medicine Total Recovery — following program completion, 5 of the 24 participants resumed alcohol consumption, of whom 4 regained remission and 1 person was lost to follow-up; out of 10 individuals who declined program participation, 6 individuals continued to drink, of whom 3 individuals died and 3 individuals failed to achieve remission; I-LEARN — preliminary data show promising results

Treatment of ALD

Medications: naltrexone, acamprosate, and disulfiram (not used secondary to hepatotoxicity) are approved by the United States Food and Drug Administration (FDA) for treatment of relapse, while medications without FDA approval include gabapentin and baclofen; limited randomized data exist with regard to medication safety and efficacy

Safety and efficacy of naltrexone (Varshney et al [2023]): at 12 mo, 7% of patients with ALD taking naltrexone experienced new-onset hepatic decompensation, vs 14% taking placebo; abstinence rates were higher among patients taking naltrexone; adverse events were higher with naltrexone (41% vs 26%) but did not require discontinuation

Role of spironolactone: Farokhnia et al (2022) — demonstrated that escalating doses of spironolactone were associated with decreased binge use of alcohol and alcohol consumption among rats, with mild sex differences; a retrospective cohort study demonstrated lower alcohol use disorders identification test-consumption scores with higher levels of spironolactone use among patients with AUD considered high risk for development of ALD; Luther et al (2023) — demonstrated reduced incidence of ALD among patients with AUD who received ≥3 prescriptions of spironolactone; drinking score was significantly higher among patients not treated with spironolactone

Intervention in early-stage ALD: Rutledge et al (2023) found that patients with AUD who received feedback regarding their condition showed a significant increase in readiness to stop drinking, compared with those who did not receive feedback

Alcohol abstinence following LT: Dukewich et al (2023) — found that patients who regained abstinence from alcohol following LT had exactly the same long-term survival and outcomes as patients who never relapsed at all; QuickTrans trial (Louvet et al [2022]) — demonstrated an alcohol use relapse rate of ≈35% among patients with AH who underwent early LT, compared with relapse rate of ≈25% of patients who underwent LT after ≥6 mo of abstinence

Readings

Crabb D, Im G, Szabo G, et al. Diagnosis and treatment of alcohol-associated liver diseases: 2019 practice guidance from the American Association for the Study of Liver Diseases. Hepatology. 2020;71(1):306-333. doi:10.1002/hep.30866; Dukewich M, Dodge JL, Lucey MR, et al. Novel patterns and survival effects of re-abstinence after harmful alcohol use following early liver transplant for severe alcohol-associated hepatitis: an ACCELERATE study. Hepatology. 2023;78:S1629-S-1631; Farokhnia M, Rentsch CT, Chuong V, et al. Spironolactone as a potential new pharmacotherapy for alcohol use disorder: convergent evidence from rodent and human studies. Mol Psychiatry. 2022;27(11):4642-4652. doi:10.1038/s41380-022-01736-y; Idalsoaga F, Díaz LA, Corsi O, et al. P-19 characterization, prognostic factors, and survival in moderate alcohol-associated hepatitis: a multicenter study. Ann Hepatol. 2024;29:101206-101206. doi:10.1016/j.aohep.2023.101206; Louvet A, Labreuche J, Moreno C, et al. Early liver transplantation for severe alcohol-related hepatitis not responding to medical treatment: a prospective controlled study. Lancet Gastroenterol Hepatol. 2022;7(5):416-425. doi:10.1016/S2468-1253(21)00430-1; Luther J, Vannier AGL, Zhang W, et al. Spironolactone therapy associated with reduced incident alcohol-associated liver disease in high risk patients: a retrospective cohort study. Hepatology. 2023;78:S176-S177; Rutledge S, Nathani RR, Arosemena PM, et al. Transient elastography increases readiness for change in inpatients with alcohol use disorder: a prospective pilot study (ELISA). Hepatology. 2023;78:S1665-S1666; Vannier AGL, Shay JES, Fomin V, et al. Incidence and progression of alcohol-associated liver disease after medical therapy for alcohol use disorder. JAMA Netw Open. 2022;5(5):e2213014. doi:10.1001/jamanetworkopen.2022.13014.

Disclosures

For this program, the following relevant financial relationships were disclosed and mitigated to ensure that no commercial bias has been inserted into this content: Dr. Mellinger was a consultant for GlaxoSmithKline. Members of the planning committee reported nothing relevant to disclose. Dr. Mellinger's lecture includes information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Mellinger was recorded at the Liver Disease Wrap-up, held on December 9, 2023, in Plymouth, MI, and presented by University of Michigan Medical School. For information on upcoming CME activities from this presenter, please visit https://medicine.umich.edu. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

GE381502

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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