What is the medical management of alcoholic cirrhosis?

Medical Management of Alcoholic Cirrhosis

Complete alcohol abstinence is the cornerstone of treatment for alcoholic cirrhosis and represents the most important therapeutic goal to reduce the risk of complications and mortality. 1

Primary Management Approach

• Alcohol abstinence significantly reduces the risks of complications and mortality in patients with alcoholic cirrhosis 2, 1
• Psychiatric consultation is essential for evaluation, treatment, and long-term planning of alcohol abstinence 1
• Baclofen is useful and safe as an anti-craving medication in patients with advanced liver disease, while disulfiram should be avoided due to potential hepatotoxicity 2, 1
• Brief interventions using the FRAMES model (Feedback, Responsibility, Advice, Menu, Empathy, Self-efficacy) should be implemented to encourage abstinence 1
• Medical discussions about alcohol use disorder treatment significantly increase the likelihood of patients receiving treatment and improving outcomes 3

Nutritional Support

• Aggressive nutritional therapy rich in calories and proteins is essential for patients with alcoholic cirrhosis 2, 1
• Protein intake of 1.2-1.5 g/kg/day is recommended to prevent muscle wasting, contrary to previous recommendations of protein restriction 1, 4
• Thiamine supplementation (100-300 mg/day) should be given to all patients with alcohol withdrawal syndrome and maintained for 2-3 months 1
• In severe cases of malnutrition, consultation with a dietitian is recommended 2, 1

Management of Cofactors

• Identify and manage cofactors including obesity, insulin resistance, malnutrition, cigarette smoking, iron overload, and viral hepatitis 2, 1
• Cigarette smoking has been identified as a predictor of mortality in alcoholic cirrhosis 2
• Screen for alcohol-induced damage to other organs including heart, kidney, nervous system, and pancreas 1

Management of Cirrhosis Complications

• Hepatic encephalopathy is associated with the highest mortality among complications of decompensated cirrhosis 2, 1
• For ascites management in cirrhosis, start with single morning doses of oral spironolactone (100 mg) and furosemide (40 mg), adjusting dosage every 7 days as needed 1, 5
• Diuretic dosage should be adjusted to achieve weight loss of no more than 0.5 kg/day in patients without peripheral edema and 1 kg/day in those with peripheral edema 6
• Monitor serum sodium closely, as hyponatremia may be exacerbated by diuretic therapy; consider temporarily stopping diuretics if serum sodium decreases below 120-125 mmol/L 6
• Primary and secondary prophylaxis of variceal bleeding should follow standard cirrhosis guidelines 1

Specific Pharmacological Therapies

• For severe alcoholic hepatitis with Maddrey Discriminant Factor ≥32, pentoxifylline and/or corticosteroids should be offered unless contraindicated 1, 7
• Corticosteroid therapy is associated with improved 1-month survival from 65% in untreated patients to 80% in treated patients in severe alcoholic hepatitis 7
• Several specific therapies tested in patients with alcoholic cirrhosis including S-adenosyl-L-methinonine (SAMe), propylthiouracil, colchicine, anabolic–androgenic steroids, and silymarin have revealed no consistent beneficial effects on patient outcome 2
• N-acetylcysteine may be useful in patients with severe alcoholic hepatitis receiving corticosteroids 1

Liver Transplantation

• Liver transplantation is the most effective therapeutic option for end-stage liver disease 1, 7
• The Model for End-Stage Liver Disease (MELD) score should be used to establish prognosis and prioritize for liver transplantation 2, 1
• Most programs require a 6-month period of abstinence prior to evaluation for transplantation 2, 1
• Graft and patient survival rates among alcoholics after liver transplantation are similar to those seen after transplantation for other etiologies of liver disease 2, 1
• Early liver transplant may be appropriate in highly select patients with severe alcoholic hepatitis who do not respond to medical therapy 7

Monitoring and Follow-up

• Perform frequent measurements of serum creatinine, sodium, and potassium during the first weeks of treatment, especially when using diuretics 6
• Ten-year survival of patients with alcohol-associated liver disease is 88% among those who are abstinent and 73% for those who relapse to alcohol consumption 7
• The persistence of alcohol abuse after diagnosis is the most important factor increasing the risk of complications and death 2