What are the treatment guidelines for a patient with active chronic liver disease caused by alcohol?

Management of Active Chronic Alcoholic Liver Disease

Total alcohol abstinence is the single most important treatment for all patients with alcoholic liver disease (ALD), as it improves survival, prevents progression to cirrhosis, and reduces portal pressure across all disease stages. 1, 2, 3

Initial Assessment and Screening

• Screen all patients routinely using the AUDIT (Alcohol Use Disorders Identification Test), which is the gold standard screening tool for alcohol abuse and dependence 1
• Assess for acute alcohol withdrawal syndrome (tremors, anxiety, agitation, seizures, delirium tremens), which typically occurs within 6-24 hours after the last drink 3
• Evaluate disease severity and stage (simple steatosis, steatohepatitis, fibrosis, cirrhosis) to guide treatment decisions 1
• Assess nutritional status, as malnutrition is common and significantly impacts outcomes 1, 3

Acute Withdrawal Management

• Benzodiazepines are the treatment of choice for acute alcohol withdrawal syndrome and prevention of seizures (options include lorazepam, diazepam, chlordiazepoxide) 1, 3
• Administer thiamine 100-300 mg/day for 4-12 weeks BEFORE any glucose-containing IV fluids to prevent Wernicke encephalopathy 3
• Admit patients with significant withdrawal symptoms, high recent drinking levels, history of withdrawal seizures/delirium tremens, or serious medical/psychiatric comorbidity 3

Pharmacologic Therapy for Alcohol Abstinence

For Patients WITHOUT Advanced Liver Disease:

• Disulfiram, naltrexone, or acamprosate combined with counseling reduce alcohol consumption and prevent relapse 1
• Acamprosate dosing: 1,998 mg/day for patients ≥60 kg 3
• Naltrexone dosing: 50-100 mg daily 4

For Patients WITH Advanced Liver Disease:

• Baclofen is the preferred medication, as it is safe and effective for preventing alcohol relapse in advanced ALD 1, 2, 3
• Baclofen dosing: titrate up to 80 mg/day over 12 weeks 3
• Acamprosate is an alternative option for maintaining abstinence 1, 2, 3
• AVOID naltrexone and disulfiram in advanced liver disease due to hepatotoxicity risk 1, 2, 3, 4

Psychosocial Interventions (Mandatory Component)

• Brief motivational interventions using the FRAMES model should be routinely implemented (Feedback, Responsibility, Advice, Menu of alternatives, Empathy, Self-efficacy) 1, 2, 3
• Brief interventions reduce drinking by an average of 57 g per week in men and lower alcohol-related morbidity and mortality 1
• Implement structured psychotherapy including cognitive behavioral therapy, motivational enhancement therapy, and 12-step facilitation 1, 3
• Encourage participation in Alcoholics Anonymous or similar peer support groups 3, 4
• Psychosocial treatment must continue indefinitely, as pharmacotherapy alone is insufficient 3

Nutritional Support

• Provide protein intake of 1.2-1.5 g/kg/day and caloric intake of 35-40 kcal/kg/day 1, 2, 3
• Use multiple smaller meals if three regular meals cannot provide adequate nutrition 2
• Supplement with vitamins and minerals: vitamin A, thiamine, vitamin B12, folic acid, pyridoxine, vitamin D, and zinc 2
• Consider branched-chain amino acid supplementation at 34 g/day if cirrhosis is present, as this reduces hospitalizations due to complications (infection, bleeding, ascites, hepatic encephalopathy) 1, 3

Management of Severe Alcoholic Hepatitis

• Calculate Modified Discriminant Function (MDF) score or MELD score to assess severity 3
• For severe alcoholic hepatitis (MDF ≥32 or MELD ≥18), prescribe prednisolone 40 mg/day for 28 days 2, 3
• Assess response to steroid treatment at 7 days using early change in bilirubin level (ECBL) or Lille model score 2

Critical Pitfalls to Avoid

• Never use naltrexone or disulfiram in patients with advanced liver disease due to hepatotoxicity risk 1, 2, 3, 4
• Always give thiamine before glucose-containing IV fluids to prevent Wernicke encephalopathy 3
• Do not rely on pharmacotherapy alone—psychosocial interventions are equally essential and must continue long-term 3
• Failure to provide adequate nutritional support worsens outcomes in malnourished ALD patients 2, 3
• Delaying corticosteroid therapy in appropriate candidates with severe alcoholic hepatitis worsens outcomes 2

Follow-Up Strategy

• Monitor regularly for abstinence maintenance, liver function tests, disease progression, medication adherence, and continued psychosocial support engagement 3
• Coordinate with community alcohol counseling centers for regular abstinence meetings, family meetings, and psychoeducation 1
• Continue structured psychotherapy and peer support indefinitely, as relapse rates can reach 50% at one year 4