What is the best course of action for a patient with alcoholic hepatitis, hypertension, and hyperlipidemia who has resumed alcohol use after a period of sobriety and is experiencing low mood, feelings of despair, and a pruritic rash on the left anterior foot and ankle?

Management of Alcohol Use Disorder in a Patient with Alcoholic Hepatitis and Comorbid Depression

This patient requires immediate initiation of baclofen for alcohol cessation combined with mandatory referral to mental health services for depression management, while avoiding naltrexone entirely due to hepatotoxicity risk in alcoholic liver disease. 1

Immediate Pharmacotherapy for Alcohol Cessation

Baclofen is the only anti-craving medication that should be used in patients with alcoholic liver disease, as it has been formally tested in randomized clinical trials in cirrhotic patients and demonstrates safety and efficacy at doses not exceeding 80 mg/day. 1, 2 This is critical because:

• Naltrexone must be completely avoided in patients with alcoholic liver disease due to significant hepatotoxicity risk, as explicitly warned by the American College of Gastroenterology and European Association for the Study of the Liver. 3, 1
• Acamprosate represents a safe alternative with no hepatotoxicity risk and can be used at 1,998 mg/day (for patients ≥60 kg) to reduce withdrawal effects and craving for 3-6 months. 1, 4
• Disulfiram should never be used in patients with alcoholic liver disease due to potential hepatotoxicity. 1

The patient's history of alcoholic hepatitis without ascites indicates ongoing liver damage, and continued alcohol use is directly associated with disease progression and mortality. 5 Even small amounts of alcohol consumption after the onset of liver disease increase the risk of severe consequences including death. 2

Mandatory Psychosocial Interventions

Medication alone is insufficient and will fail without intensive psychosocial support. 4 This patient requires:

• Immediate referral to Alcoholics Anonymous (AA) with active encouragement for regular attendance, as AA is highly effective and should be routinely recommended as part of comprehensive treatment per the National Institute on Alcohol Abuse and Alcoholism. 3, 1
• Cognitive behavioral therapy (CBT) to help develop coping skills and address the psychological patterns underlying his drinking behavior, particularly given his endorsement of low mood, despair, and use of alcohol as a coping mechanism. 3, 1
• Individual psychotherapy to help the patient accept lack of control over alcohol, provide education regarding alcohol dependence, and achieve self-control to maintain abstinence. 1

The patient's military background, reminiscing about his platoon, and symptoms of depression suggest possible PTSD or adjustment disorder requiring specialized mental health evaluation beyond standard addiction counseling.

Critical Management of Depression and Suicide Risk

The patient's low mood, feelings of despair, and alcohol use as a coping mechanism represent a psychiatric emergency requiring immediate mental health referral, even though he currently denies suicidal ideation. 3 Depression significantly increases relapse risk and must be treated concurrently with alcohol use disorder. Regular monitoring for emerging suicidal ideation is essential, as relapse rates can reach 50% at one year even with treatment. 3

Addressing the Pruritic Rash

The pruritic rash on the left anterior foot and ankle likely represents a fungal infection (tinea pedis) given the intermittent pruritus and lack of improvement with previous treatment. This should be managed with:

• Topical antifungal therapy (e.g., terbinafine or clotrimazole cream) applied twice daily for 2-4 weeks
• If the patient was previously prescribed an oral antifungal and instructed not to drink while taking it, this was likely fluconazole or another azole antifungal that can have additive hepatotoxicity with alcohol

The rash management is secondary to the life-threatening alcohol use disorder and should not distract from the primary focus on achieving abstinence.

Absolute Abstinence Requirement

Complete lifelong abstinence from alcohol is the only acceptable recommendation for this patient with alcoholic hepatitis. 5 There is no safe amount of alcohol consumption that can be recommended, as alcoholic hepatitis can persist or redevelop with any alcohol intake. 5 The significant risk of recidivism in patients who attempt to cut back but not stop drinking altogether makes "harm reduction" approaches inappropriate in this context. 4

Ten-year survival is 88% among patients with alcohol-associated liver disease who remain abstinent versus 73% for those who relapse. 6 Without treatment and abstinence, mortality within 90 days is 40-50%. 5

Monitoring and Follow-Up Strategy

Regular follow-up appointments every 1-3 months are necessary to assess progress, monitor liver function, evaluate medication compliance, and adjust treatment. 3, 4 Specific monitoring should include:

• Liver function tests at baseline and every 3-6 months to track disease progression 4
• Assessment of alcohol abstinence through patient report, collateral information, and consideration of biomarkers if compliance is questionable 1
• Evaluation of depression symptoms and suicide risk at each visit 3
• Medication compliance verification, as non-compliance is a major cause of treatment failure 4

Common Pitfalls to Avoid

• Never recommend "cutting back" instead of complete abstinence in a patient with established alcoholic liver disease. 4
• Do not delay mental health referral despite the patient's initial reluctance, as depression significantly worsens outcomes and increases relapse risk. 3
• Do not rely on AA attendance alone for this patient with severe dependence and psychiatric comorbidities who requires intensive professional treatment. 3
• Do not prescribe naltrexone despite its effectiveness in other populations, as hepatotoxicity risk is unacceptable in alcoholic liver disease. 3, 1
• Continue medication for a minimum of 3-6 months, with longer durations for patients with recurrent relapses like this patient. 4