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: Aditya Govindavarjhulla, M.B.B.S. [2]

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

• Abstinence from alcohol
• Counseling and family support during alcohol abstinence
• Naltrexone or acamprosate to reduce relapse
• 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 B1 consumption and B1 deficiency may lead to Wernicke–Korsakoff syndrome.
• Folic acid, thiamine, and zinc supplements are recommended.

Drug therapy

Alcoholic hepatitis

• Methylprednisolone
  • 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
• Pentoxifylline
• 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

Other less commonly used drugs

• Steroids + N-acetylcysteine
• Propylthiouracil
• Oxandrolone
• S-adenosyl-L-methionine
• Infliximab

Contraindicated medications

Alcoholic liver disease is considered an absolute contraindication to the use of the following medications:

• Methotrexate

2010 AASLD/ACG Alcoholic Liver Disease Guidelines (DO NOT EDIT)

Abstinence (DO NOT EDIT)

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)

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)

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)"