What supplements are used for the treatment of alcohol-induced liver disease?

Supplements for Alcohol-Induced Liver Disease

Vitamin and mineral supplementation should be provided along with nutritional therapy to all patients with alcohol-induced liver disease, specifically including thiamine, vitamin A, vitamin B12, folic acid, pyridoxine, vitamin D, and zinc. 1

Essential Vitamin and Mineral Supplementation

B-Complex Vitamins (Priority)

• B-complex vitamin supplementation is recommended in all patients with alcoholic hepatitis to prevent Wernicke's encephalopathy, regardless of disease severity 1
• Thiamine is particularly critical given the high risk of neurological complications in this population 1
• Additional B vitamins including vitamin B12, folic acid, and pyridoxine should be supplemented in patients with documented nutritional deficiency 1

Zinc Supplementation

• Therapeutic doses of zinc should be considered in moderate and severe alcoholic hepatitis given that most patients with chronic alcohol abuse are zinc-deficient 1
• Zinc has been shown to improve gut mucosal barrier integrity in animal models of ALD and small pilot human trials, which is relevant since gut-derived pathogen-associated molecules contribute to alcoholic hepatitis pathogenesis 1

Fat-Soluble Vitamins

• Vitamin A supplementation should be provided to patients with documented deficiency 1
• Caution: Avoid combining vitamin A or beta-carotene supplementation with ongoing alcohol consumption, as this combination potentiates hepatotoxicity 2
• Vitamin D should be supplemented in deficient patients 1

Supplements NOT Recommended

Antioxidant Supplements

• Antioxidant supplements (beta-carotene, vitamins A, C, E, and selenium) are NOT recommended for treatment of alcoholic hepatitis 1
• A meta-analysis found no evidence of benefit from these antioxidant studies 1
• A direct comparison showed worse outcomes in the antioxidant group compared to corticosteroids 1

Other Agents Without Proven Benefit

• S-adenosyl-L-methionine (SAMe): Despite theoretical rationale, a Cochrane review found insufficient evidence to support its use 1
• Propylthiouracil (PTU): A Cochrane review of 6 randomized controlled trials showed no benefit over placebo on mortality or liver-related complications 1
• Colchicine, anabolic-androgenic steroids, and silymarin: These did not demonstrate consistent benefits on clinical endpoints 1

Nutritional Support Framework

Caloric and Protein Requirements

• Daily energy intake of 35-40 kcal/kg body weight and protein intake of 1.2-1.5 g/kg body weight are recommended 1
• In critically ill patients, consider higher targets: 1.5 g/kg/day protein and 40 kcal/kg/day calories 1
• Patients consuming fewer than 21.5 kcal/kg/day while receiving corticosteroids have significantly increased infection rates and 6-month mortality (65.8% vs 33.1%) 1

Delivery Methods

• Enteral nutritional supplements are recommended, representing a 36% risk reduction in mortality (hazard ratio 0.64; 95% CI 0.48-0.86) 1
• If three meals daily provide inadequate nutrition, add early morning and late-night snacks 1
• Frequent interval feedings with emphasis on nighttime snack and morning feeding improve nitrogen balance 1
• Tube feeding should be considered if patients cannot maintain adequate oral intake, though tolerance can be problematic 1

Branched-Chain Amino Acids

• Long-term supplementation with branched-chain amino acids (34 g/day) reduces hospitalizations due to complications including infection, gastrointestinal bleeding, ascites, and hepatic encephalopathy in alcoholic liver cirrhosis 1
• These supplements improve nitrogen balance, hepatic encephalopathy, and liver function tests 1

Common Pitfalls to Avoid

• Do not restrict protein intake in alcoholic cirrhosis patients, even with hepatic encephalopathy—adequate protein is essential 3
• Avoid intensive enteral nutrition via nasogastric tube combined with corticosteroids, as a recent multicenter trial showed no survival benefit and poor tube tolerance 1
• Do not use disulfiram in patients with ALD due to potential hepatotoxicity 1
• Monitor carefully if using acetaminophen/paracetamol, particularly in malnourished patients with ALD cirrhosis 1