What is the management of alcoholic liver disease?

Management of Alcoholic Liver Disease

The management of alcoholic liver disease (ALD) requires complete alcohol abstinence as the most effective intervention to prevent disease progression and improve outcomes across all stages of the disease. 1

Screening and Diagnosis

• The Alcohol Use Disorders Identification Test (AUDIT) is the gold standard screening tool for alcohol abuse and dependence in patients with suspected ALD 1
• Diagnosis of alcohol-induced hepatitis requires clinical and laboratory parameters including:
  • Onset of jaundice within 8 weeks of last drinking period
  • Heavy drinking (>40 g/day) for more than 6 months
  • Serum bilirubin >3.0 mg/dL
  • Serum AST >50 IU/L but <400 IU/L
  • AST/ALT ratio >1.5 2
• Severity assessment should be performed using validated scoring systems such as Maddrey discriminant function (MDF) >32 or MELD score >20 2

Treatment Approach by Disease Stage

General Management for All ALD Patients

• Total alcohol abstinence is essential and represents the cornerstone of therapy 1
• Brief motivational interventions should be routinely used in the medical management of alcohol use disorders 1
• In patients with acute alcohol withdrawal syndrome, benzodiazepines are the treatment of choice 1
• Nutritional support with 1-1.5 g protein and 30-40 kcal/kg body weight daily should be provided 2

Management of Alcohol Dependence

• For patients without advanced ALD, disulfiram, naltrexone, and acamprosate combined with counseling can reduce alcohol consumption and prevent relapse 1
• These medications should not be used in patients with advanced ALD due to potential side effects 1
• Baclofen has demonstrated safety and efficacy in preventing alcohol relapse in patients with advanced ALD 1, 3

Management of Alcoholic Hepatitis

• For severe alcoholic hepatitis (MDF >32 or MELD >20), first-line treatment is corticosteroids (prednisolone 40 mg/day or methylprednisolone 32 mg/day) for 28 days 2
• Response to corticosteroids should be assessed at day 7 using the Lille score 2
• N-acetylcysteine combined with corticosteroids may be considered for patients with contraindications to corticosteroids alone 2
• Systematic screening for infections (blood cultures, urine cultures, and ascites fluid culture if present) is mandatory before initiating treatment 2

Management of Alcoholic Cirrhosis

• Identification and management of cofactors including obesity, insulin resistance, malnutrition, cigarette smoking, iron overload, and viral hepatitis are recommended 1
• General recommendations for screening and management of complications of cirrhosis should be applied 1
• For hepatic encephalopathy, lactulose is indicated for prevention and treatment 4
• No specific pharmacological therapy for alcoholic cirrhosis has demonstrated unequivocal efficacy beyond abstinence 1

Monitoring and Follow-up

• Combining the Lille and MELD scores provides optimal prediction of short and medium-term mortality risk in alcoholic hepatitis 2
• Extensive bacteriological examination should be performed if symptoms or signs of infection develop during treatment 2
• Long-term outcomes depend primarily on maintaining abstinence, with 5-year survival rates of approximately 80% if abstinence is maintained 2

Common Pitfalls and Caveats

• Patients with alcoholic hepatitis have impaired immune response, placing them at high risk for bacterial and fungal infections 2
• Development of multi-organ failure is associated with very high mortality 2
• Corticosteroid therapy improves short-term (28-day) survival but shows no significant benefit at 3 months and beyond 2
• Other laxatives should not be used during the initial phase of therapy for hepatic encephalopathy as they may falsely suggest that adequate lactulose dosage has been achieved 4
• Non-absorbable antacids given concurrently with lactulose may inhibit the desired lactulose-induced drop in colonic pH 4