Alcoholic liver disease medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: M. Khurram Afzal, MD [2] Aditya Govindavarjhulla, M.B.B.S. [3]
Overview
The most important part of treatment is to stop using alcohol completely. If liver cirrhosis has not yet occurred, the liver can heal if you stop drinking alcohol. An alcohol rehabilitation program or counseling may be necessary to break the alcohol addiction. Vitamins, especially B-complex and folic acid, can help reverse malnutrition. If cirrhosis develops, there is a need to manage the complications of cirrhosis. It may need a liver transplant.
Medical therapy
General Therapy
General therapy for alcoholic liver disease includes:[1][2][3][4][5][6][7][8][9][10][11][12][13][14]
- Abstinence from alcohol has been shown to lead to resolution of hepatic steatosis and slow the progression of alcoholic fibrosis, cirrhosis and decompensated liver failure.
- Counseling and family support during alcohol abstinence.
- Assessment and treatment of underlying psychiatric conditions.
- Naltrexone or acamprosate to reduce relapse.
- Disulfiram, under supervision and topiramate for decreasing craving and withdrawal symptoms have also been approved to be used for treating alcohol dependence.
- Baclofen has been shown to treat alcohol dependence in patients who are actively consuming alcohol and have liver cirrhosis.
- Smoking cessation and weight loss where indicated is very important in the treatment of alcoholic liver disease as they are both independent risk factors for development of hepatic fibrosis and cirrhosis.
- Nutritional support - Adequate amounts of carbohydrates and calories as alcoholics are commonly malnourished. This prevents endogenous protein catabolism, and hypoglycemia. Administration of thiamine is important with glucose supplements. This is so because glucose administration increases vitamin B1 consumption and vitamin B1 deficiency may lead to Wernicke–Korsakoff syndrome.
- Folic acid, thiamine, vitamin B6, vitamin A and zinc supplements are recommended.
- Nutritional support guidelines; 1.2–1.5 g/kg of protein and 35–40 kcal/kg of body weight per day in patients suffering from alcoholic liver disease.
Pharmacotherapy
Alcoholic hepatitis
- Glucocorticoids[15][16][17][18][19][20][21][22]
- Beneficial in patients with hepatic encephalopathy, Maddrey's discriminant function score ≥32, or a MELD score ≥21.
- Decreases short term mortality.
- Usually given for 1 month.
- Serum bilirubin is used as a predictor for treatment success. Failure of the serum bilirubin level to decline after 7 days of treatment predicts poor prognosis.
- Another predictor of treatment is Lille model comprising, age, serum creatinine, serum albumin, prothrombin time (or INR), serum bilirubin on admission, and serum bilirubin on day 7.
- Contraindicated in the presence of sepsis, hepatorenal syndrome, chronic hepatitis B virus infection and gastrointestinal bleeding.
- Pentoxifylline[23][24][23][25][26][27]
- It is a tumor necrosis factor inhibitor.
- Used in patients with contraindications to steroids.
- Usually given for 1 months.
- Decreases mortality.
- Decreases risk of hepatorenal syndrome.
- S-adenosylmethionine.
- Silymarin (silybum marianum-milk thistle).
2010 AASLD/ACG Alcoholic Liver Disease Guidelines (DO NOT EDIT)[33]
Abstinence (DO NOT EDIT)[33]
| Class I |
| 1. " In patients with evidence of alcohol-induced liver disease, strict abstinence must be recommended, because continued alcohol use is associated with disease progression.(Level of evidence: B) " |
| 2. " Naltrexone or acamprosate may be considered in combination with counseling to decrease the likelihood of relapse in patients with alcohol abuse/dependence in those who achieve abstinence. (Level of evidence: A) " |
Treatment of Alcohol Hepatitis (DO NOT EDIT)[33]
| Class I |
| 1. " All patients with alcoholic hepatitis should be counseled to completely abstain from alcohol. (Level of evidence: B) " |
| 2." All patients with alcoholic hepatitis or advanced ALD should be assessed for nutritional deficiencies (protein-calorie malnutrition), as well as vitamin and mineral deficiencies. Those with severe disease should be treated aggressively with enteral nutritional therapy.(Level of evidence: B)" |
| 3." Patients with severe disease (MDF score of >32, with or without hepatic encephalopathy) and lacking contraindications to steroid use should be considered for a four week course of prednisolone (40 mg/day for 28 days, typically followed by discontinuation or a 2-week taper).(Level of evidence: A)" |
| 4." Patients with severe disease (i.e., a MDF >32) could be considered for pentoxifylline therapy (400 mg orally 3 times daily for 4 weeks), especially if there are contraindications to steroid therapy.(Level of evidence: B)" |
| Class III (No Benefit) |
| 1. " Patients with mild-moderate alcoholic hepatitis—defined as a Maddrey score of <32, without hepatic encephalopathy, and with improvement in serum bilirubin or decline in the MDF during the first week of hospitalization—should be monitored closely, but will likely not require nor benefit from specific medical interventions other than nutritional support and abstinence.(Level of evidence: A)" |
Long-term Management (DO NOT EDIT)[33]
| Class I |
| 1." Patients with alcoholic cirrhosis should receive frequent interval feedings, emphasizing a night time snack and morning feeding, to improve nitrogen balance. (Level of evidence: B) " |
| Class III (No Benefit) |
| 1. "Propylthiouracil (PTU) and colchicine should not be used in the treatment of patients with ALD; S-adenosyl L-methionine (SAMe) should be used only in clinical trials.(Level of evidence: A)" |
| 2. "The use of complementary or alternative medicines in the treatment of either acute or chronic alcohol-related liver disease has shown no convincing benefit and should not be used out of the context of clinical trial.(Level of evidence: A)" |
References
- ↑ Sofair AN, Barry V, Manos MM, Thomas A, Zaman A, Terrault NA, Murphy RC, Stabach N, Huie S, Van Ness G, Bell BP, Bialek S (2010). "The epidemiology and clinical characteristics of patients with newly diagnosed alcohol-related liver disease: results from population-based surveillance". J. Clin. Gastroenterol. 44 (4): 301–7. doi:10.1097/MCG.0b013e3181b3f760. PMID 19745759.
- ↑ Heron M, Hoyert DL, Murphy SL, Xu J, Kochanek KD, Tejada-Vera B (2009). "Deaths: final data for 2006". Natl Vital Stat Rep. 57 (14): 1–134. PMID 19788058.
- ↑ Kaner EF, Dickinson HO, Beyer F, Pienaar E, Schlesinger C, Campbell F, Saunders JB, Burnand B, Heather N (2009). "The effectiveness of brief alcohol interventions in primary care settings: a systematic review". Drug Alcohol Rev. 28 (3): 301–23. doi:10.1111/j.1465-3362.2009.00071.x. PMID 19489992.
- ↑ Moos RH, King MJ, Patterson MA (1996). "Outcomes of residential treatment of substance abuse in hospital- and community-based programs". Psychiatr Serv. 47 (1): 68–74. doi:10.1176/ps.47.1.68. PMID 8925349.
- ↑ Bouza C, Angeles M, Magro A, Muñoz A, Amate JM (2004). "Efficacy and safety of naltrexone and acamprosate in the treatment of alcohol dependence: a systematic review". Addiction. 99 (7): 811–28. doi:10.1111/j.1360-0443.2004.00763.x. PMID 15200577.
- ↑ Garbutt JC, West SL, Carey TS, Lohr KN, Crews FT (1999). "Pharmacological treatment of alcohol dependence: a review of the evidence". JAMA. 281 (14): 1318–25. PMID 10208148.
- ↑ Kenna GA, Lomastro TL, Schiesl A, Leggio L, Swift RM (2009). "Review of topiramate: an antiepileptic for the treatment of alcohol dependence". Curr Drug Abuse Rev. 2 (2): 135–42. PMID 19630744.
- ↑ Addolorato G, Leggio L, Ferrulli A, Cardone S, Vonghia L, Mirijello A, Abenavoli L, D'Angelo C, Caputo F, Zambon A, Haber PS, Gasbarrini G (2007). "Effectiveness and safety of baclofen for maintenance of alcohol abstinence in alcohol-dependent patients with liver cirrhosis: randomised, double-blind controlled study". Lancet. 370 (9603): 1915–22. doi:10.1016/S0140-6736(07)61814-5. PMID 18068515.
- ↑ Corrao G, Lepore AR, Torchio P, Valenti M, Galatola G, D'Amicis A, Aricó S, di Orio F (1994). "The effect of drinking coffee and smoking cigarettes on the risk of cirrhosis associated with alcohol consumption. A case-control study. Provincial Group for the Study of Chronic Liver Disease". Eur. J. Epidemiol. 10 (6): 657–64. PMID 7672043.
- ↑ Klatsky AL, Armstrong MA (1992). "Alcohol, smoking, coffee, and cirrhosis". Am. J. Epidemiol. 136 (10): 1248–57. PMID 1476147.
- ↑ Naveau S, Giraud V, Borotto E, Aubert A, Capron F, Chaput JC (1997). "Excess weight risk factor for alcoholic liver disease". Hepatology. 25 (1): 108–11. doi:10.1002/hep.510250120. PMID 8985274.
- ↑ Halsted CH (2004). "Nutrition and alcoholic liver disease". Semin. Liver Dis. 24 (3): 289–304. doi:10.1055/s-2004-832941. PMID 15349806.
- ↑ Kang YJ, Zhou Z (2005). "Zinc prevention and treatment of alcoholic liver disease". Mol. Aspects Med. 26 (4–5): 391–404. doi:10.1016/j.mam.2005.07.002. PMID 16099027.
- ↑ McCullough AJ, O'Connor JF (1998). "Alcoholic liver disease: proposed recommendations for the American College of Gastroenterology". Am. J. Gastroenterol. 93 (11): 2022–36. doi:10.1111/j.1572-0241.1998.00587.x. PMID 9820369.
- ↑ Addolorato G, Russell M, Albano E, Haber PS, Wands JR, Leggio L (2009). "Understanding and treating patients with alcoholic cirrhosis: an update". Alcohol. Clin. Exp. Res. 33 (7): 1136–44. doi:10.1111/j.1530-0277.2009.00956.x. PMID 19389182.
- ↑ Christensen E (2002). "Alcoholic hepatitis--glucocorticosteroids or not?". J. Hepatol. 36 (4): 547–8. PMID 11943428.
- ↑ Ramond MJ, Poynard T, Rueff B, Mathurin P, Théodore C, Chaput JC, Benhamou JP (1992). "A randomized trial of prednisolone in patients with severe alcoholic hepatitis". N. Engl. J. Med. 326 (8): 507–12. doi:10.1056/NEJM199202203260802. PMID 1531090.
- ↑ Carithers RL, Herlong HF, Diehl AM, Shaw EW, Combes B, Fallon HJ, Maddrey WC (1989). "Methylprednisolone therapy in patients with severe alcoholic hepatitis. A randomized multicenter trial". Ann. Intern. Med. 110 (9): 685–90. PMID 2648927.
- ↑ Maddrey WC, Boitnott JK, Bedine MS, Weber FL, Mezey E, White RI (1978). "Corticosteroid therapy of alcoholic hepatitis". Gastroenterology. 75 (2): 193–9. PMID 352788.
- ↑ Rambaldi A, Saconato HH, Christensen E, Thorlund K, Wetterslev J, Gluud C (2008). "Systematic review: glucocorticosteroids for alcoholic hepatitis--a Cochrane Hepato-Biliary Group systematic review with meta-analyses and trial sequential analyses of randomized clinical trials". Aliment. Pharmacol. Ther. 27 (12): 1167–78. doi:10.1111/j.1365-2036.2008.03685.x. PMID 18363896.
- ↑ O'Shea R, McCullough AJ (2006). "Steroids or cocktails for alcoholic hepatitis". J. Hepatol. 44 (4): 633–6. doi:10.1016/j.jhep.2006.01.011. PMID 16503078.
- ↑ "LilleModel".
- ↑ 23.0 23.1 Akriviadis E, Botla R, Briggs W, Han S, Reynolds T, Shakil O (2000). "Pentoxifylline improves short-term survival in severe acute alcoholic hepatitis: a double-blind, placebo-controlled trial". Gastroenterology. 119 (6): 1637–48. PMID 11113085.
- ↑ Assimakopoulos SF, Thomopoulos KC, Labropoulou-Karatza C (2009). "Pentoxifylline: a first line treatment option for severe alcoholic hepatitis and hepatorenal syndrome?". World J. Gastroenterol. 15 (25): 3194–5. PMC 2705746. PMID 19575503.
- ↑ Louvet A, Diaz E, Dharancy S, Coevoet H, Texier F, Thévenot T, Deltenre P, Canva V, Plane C, Mathurin P (2008). "Early switch to pentoxifylline in patients with severe alcoholic hepatitis is inefficient in non-responders to corticosteroids". J. Hepatol. 48 (3): 465–70. doi:10.1016/j.jhep.2007.10.010. PMID 18164508.
- ↑ De BK, Gangopadhyay S, Dutta D, Baksi SD, Pani A, Ghosh P (2009). "Pentoxifylline versus prednisolone for severe alcoholic hepatitis: a randomized controlled trial". World J. Gastroenterol. 15 (13): 1613–9. PMC 2669113. PMID 19340904.
- ↑ Whitfield K, Rambaldi A, Wetterslev J, Gluud C (2009). "Pentoxifylline for alcoholic hepatitis". Cochrane Database Syst Rev (4): CD007339. doi:10.1002/14651858.CD007339.pub2. PMID 19821406.
- ↑ Lee TD, Sadda MR, Mendler MH, Bottiglieri T, Kanel G, Mato JM, Lu SC (2004). "Abnormal hepatic methionine and glutathione metabolism in patients with alcoholic hepatitis". Alcohol. Clin. Exp. Res. 28 (1): 173–81. doi:10.1097/01.ALC.0000108654.77178.03. PMID 14745316.
- ↑ Song Z, McClain CJ, Chen T (2004). "S-Adenosylmethionine protects against acetaminophen-induced hepatotoxicity in mice". Pharmacology. 71 (4): 199–208. doi:10.1159/000078086. PMID 15240996.
- ↑ McClain CJ, Hill DB, Song Z, Chawla R, Watson WH, Chen T, Barve S (2002). "S-Adenosylmethionine, cytokines, and alcoholic liver disease". Alcohol. 27 (3): 185–92. PMID 12163148.
- ↑ Ferenci P, Dragosics B, Dittrich H, Frank H, Benda L, Lochs H, Meryn S, Base W, Schneider B (1989). "Randomized controlled trial of silymarin treatment in patients with cirrhosis of the liver". J. Hepatol. 9 (1): 105–13. PMID 2671116.
- ↑ Parés A, Planas R, Torres M, Caballería J, Viver JM, Acero D, Panés J, Rigau J, Santos J, Rodés J (1998). "Effects of silymarin in alcoholic patients with cirrhosis of the liver: results of a controlled, double-blind, randomized and multicenter trial". J. Hepatol. 28 (4): 615–21. PMID 9566830.
- ↑ 33.0 33.1 33.2 33.3 "www.aasld.org" (PDF). Retrieved 2012-10-27.