November 8, 2023
3 min read
VANCOUVER, British Columbia — With alcohol-related illnesses still on the rise after emerging during the COVID-19 pandemic, an expert here discusses treatment options for people with alcoholic hepatitis, including liver transplantation.
“You have to be aware that alcoholic liver disease, especially alcoholic hepatitis, is on the rise,” Stanley M. Cohen, MD, FACG, , professor of medicine and medical director of hepatology at Case Western Reserve School of Medicine, said in a speech at the ACG annual scientific meeting. “Keep it in your mind as part of your history.”
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Cohen attributes the recent rise in alcoholic hepatitis incidence and subsequent mortality to increased alcohol consumption among young people, particularly women aged 25 to 34, and the impact of COVID-19.
Cohen cited research from the Explorys database, which divided individuals into pre-COVID and COVID-19 cohorts, noting that the results “shouldn’t be surprising to anyone here.”
“We found that the risk of alcoholic liver disease increased almost threefold,” he said. “We’re seeing varicose veins, alcoholic pancreatitis. So the bottom line is, we’re not just seeing more alcohol — we’re seeing more downstream effects.”
Cohen said alcoholic hepatitis is a special syndrome with a mortality rate of 35% to 45% within one month. “We see this frequently in hospitalized patients with alcoholic liver disease,” he said. “They are usually hospitalized for alcoholic hepatitis, and by the time we see them, most of them already have cirrhosis.”
In addition to clinical indicators, Cohen noted that the Maddrey discriminant function (MELD) is the most commonly used prognostic score, with a Maddrey above 32 and a MELD above 20 indicating the presence of severe alcoholic hepatitis.
“Why should we care? Because that’s the group we’re going to treat with steroids again. Also, that means the 90-day mortality rate is about 20 percent,” he said.
Cohen reviewed treatment options, although many of them were unsuccessful, including absolute abstinence, nutritional therapy, corticosteroids, and LT.
Although other treatments, such as pentoxifylline, have been studied, Cohen said corticosteroids remain the first-line treatment for patients without contraindications. When using steroid therapy, I recommend using the Lille score to measure effectiveness.
“It allows us to look at them on day 0 and day 7 of steroids to see if they respond,” he said. “What we’re looking for is a Lille score below 0.45: below 0.45, survival is much better. If it’s above 0.45, it’s basically futile and we stop using steroids.”
Cohen also noted that IV N-acetylcysteine could be used as an adjuvant to steroids and that granulocyte colony-stimulating factor deserves further study.
Finally, Cohen discussed how LT might be considered in a select group of patients, noting that the traditional 6-month sobriety rule “has no scientific basis.”
“We’re starting to see a paradigm shift where we can now assess people through psychologists or social workers,” he said. “We can really understand who is at higher risk for recidivism, who is not, and who is a good candidate.”
Cohen highlighted a 2011 French study that showed a 6-month survival rate of 77% in a carefully selected group of patients (who, among other factors, had no previous alcoholic liver disease) who underwent transplantation for alcoholic hepatitis; Only 10% subsequently resumed drinking. A US study of 147 similar patients showed a 3-year survival rate of 84%.
One predictive factor to consider is the Sustained Alcohol Use After Liver Transplantation (SALT) score, which “basically looks at the amount of alcohol consumed, the number of previously failed rehabs, any legal issues, and if (the patient’s) score is below 5, continued alcohol use after transplant The negative predictive value is 95%,” Cohen said.
“I don’t want you to come away thinking that transplantation would be beneficial for all of these patients, but there is a small subset that you need to consider,” he added.
Source/Disclosure
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Cohen SM. Update on the treatment of alcohol-associated hepatitis (AAH). Presented at: ACG Annual Scientific Meeting; October 20-25, 2023; Vancouver, BC (hybrid meeting).
Disclosure: Cohen describes himself as serving on advisory committees, boards of directors or speaking bureaus for AbbVie, Gilead and Intercept.
American College of Gastroenterology Annual Meeting