What is the recommended management for alcoholic liver disease, including alcohol cessation, nutritional support, treatment of alcoholic hepatitis, management of cirrhosis complications, infection surveillance, and transplant evaluation?

Management of Alcoholic Liver Disease

Alcohol abstinence is the single most important intervention that reduces mortality and prevents decompensation in alcoholic liver disease, and must be achieved through addiction specialist involvement with baclofen as the preferred anti-craving medication in advanced cirrhosis. 1, 2

Alcohol Cessation Strategy

Immediate referral to addiction specialists is mandatory, incorporating motivational therapy and ongoing psychosocial support as the foundation of treatment. 1, 2

Pharmacologic Management of Alcohol Use Disorder

• Baclofen is the preferred anti-craving medication in patients with advanced liver disease because it is safe even in decompensated cirrhosis. 1, 2
• Disulfiram is absolutely contraindicated due to potential hepatotoxicity in ALD patients. 1, 3
• Naltrexone or acamprosate combined with counseling decreases relapse likelihood in patients who achieve abstinence, with acamprosate preferred due to lack of hepatotoxicity. 2

Critical Pitfall

Even moderate alcohol consumption (0.5 g/kg) impairs hepatic venous pressure gradient within 15 minutes and can precipitate clinical decompensation. 2

Nutritional Support Protocol

Aggressive nutritional therapy is fundamental, as malnutrition affects up to 50% of patients with alcoholic cirrhosis. 1, 2

Specific Nutritional Targets

• Daily energy intake: 35-40 kcal/kg body weight 3
• Protein intake: 1.2-1.5 g/kg body weight (do NOT restrict protein even with hepatic encephalopathy) 3
• In critically ill patients: 1.5 g/kg/day protein and 40 kcal/kg/day calories 3
• Enteral nutritional supplements provide 36% mortality risk reduction (HR 0.64; 95% CI 0.48-0.86) 3
• Frequent interval feedings with emphasis on nighttime snack and morning feeding improve nitrogen balance 3

Critical Nutritional Pitfall

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%). 3

Vitamin and Mineral Supplementation

Mandatory Supplementation

• B-complex vitamins in ALL patients to prevent Wernicke's encephalopathy, regardless of disease severity 3
• Thiamine is particularly critical given high risk of neurological complications 3
• Therapeutic doses of zinc should be considered in moderate and severe alcoholic hepatitis, as most patients are zinc-deficient 3

Supplementation for Documented Deficiency

• Vitamin B12, folic acid, and pyridoxine in documented deficiency 3
• Before initiating folic acid, check vitamin B12 levels to prevent masking B12 deficiency and irreversible neurological damage 4
• If B12 deficiency present, treat with hydroxocobalamin 1 mg IM before or concurrent with folate 4
• Folic acid dose: 1-5 mg oral daily for 4 months 4
• Vitamin A in documented deficiency 3
• Vitamin D in deficient patients 3

Supplements NOT Recommended

• Antioxidant supplements (beta-carotene, vitamins A, C, E, selenium) are NOT recommended for alcoholic hepatitis treatment, as meta-analysis found no benefit 3
• S-adenosyl-L-methionine (SAMe) has insufficient evidence to support its use 3

Management of Cirrhosis Complications

All standard cirrhosis complications must be managed according to general cirrhosis guidelines, including primary and secondary prophylaxis. 1, 2

Specific Interventions

• Endoscopic surveillance of esophageal varices with primary and secondary prophylaxis of variceal bleeding 2
• Standard management of ascites, hepatic encephalopathy, and portal hypertension 1, 2
• Hepatocellular carcinoma surveillance every 6 months with ultrasonography in all patients with alcoholic cirrhosis (annual incidence 2.6%, reaching 7-16% at 5 years) 2

Management of Cofactors

Systematic identification and treatment of cofactors is a Grade B1 recommendation that improves outcomes. 1, 2

Specific Cofactors to Address

• Obesity and insulin resistance 1
• Malnutrition 1
• Cigarette smoking cessation (Grade A1 recommendation, as smoking is a predictor of mortality) 1, 2
• Iron overload 1
• Viral hepatitis (HBV/HCV) 1, 2

Evaluation of Alcohol-Induced Organ Damage

Patients should be evaluated for: 2

• Alcoholic cardiomyopathy
• IgA nephropathy
• Central and peripheral nervous system involvement
• Chronic pancreatitis

Medication Safety

• Use acetaminophen/paracetamol with extreme caution, particularly in malnourished patients with ALD cirrhosis 3, 2
• Avoid intensive enteral nutrition via nasogastric tube combined with corticosteroids, as recent multicenter trial showed no survival benefit and poor tube tolerance 3

Liver Transplantation Considerations

Most programs require a 6-month period of abstinence before transplant evaluation, though this rule's utility as a predictor of long-term sobriety is controversial. 1, 2

Transplant Outcomes

• Graft and patient survival rates are similar to other etiologies (approximately 80-85% at one year) 1, 2
• Survival benefit is restricted to patients with advanced decompensation (Child-Pugh 11-15 points) 1
• Immediate listing for Child-Pugh stage B cirrhosis does not show survival benefit and increases extrahepatic cancer risk 1
• Post-transplant, approximately 20% return to harmful drinking, which reduces survival 5

Monitoring Strategy

• Transient elastography (FibroScan) is the most reliable non-invasive method for monitoring liver fibrosis changes 2
• MELD score is commonly used to establish prognosis and list patients for transplantation 2
• Recheck folate levels within 3 months after initiating supplementation 4

Pharmacologic Therapies Without Proven Efficacy

No specific pharmacological therapy for alcoholic cirrhosis has demonstrated unequivocal efficacy (Grade A1 recommendation). 1 Tested therapies without consistent benefit include propylthiouracil, colchicine, anabolic-androgenic steroids, and silymarin. 1