Introduction: Effective treatment for alcoholism involves pharmacotherapy and psychosocial support. Naltrexone, Acamprosate, and Disulfiram are FDA-approved for moderate-severe alcoholism. Although abstinence remains the cornerstone in management of alcoholic cirrhosis (AC), these patients often have less access to treatment modalities, including pharmacotherapy. In this study, we sought to investigate the discrepancies in pharmacologic treatment of alcohol use disorder in patients with AC compared to non-cirrhotics. Methods: We queried a commercial database (Explorys Inc, Cleveland, OH), an aggregate of EHR data from 27 integrated healthcare systems in the United States between 5/2017-5/2022. We identified all patients in the database with AC and alcoholism based on Systematized Nomenclature of Medicine-Clinical Terms (SNOMED-CT). We compared the prevalence of pharmacologic treatment for alcoholism with Naltrexone, Acamprosate, or Disulfiram at least 30 days following diagnosis of AC to a control cohort of patients with alcoholism without AC. Results: Of the 31,306,880 patients in the database, 310,470 patients had a diagnosis of alcoholism, excluding AC, and 62,670 patients had AC. Overall prevalence of Acamprosate use was 1.47% in the group with AC and 2.32% in the group with alcoholism with odds ratio (OR) for AC 0.63 [95% CI, 0.59-0.67, p, 0.001]. Odds of treatment with Acamprosate tended to be lower in patients with AC who were Hispanic/Latino (OR 0.38) or had a major mood disorder such as depression (OR 0.27) or bipolar disorder (OR 0.39). Overall prevalence of Naltrexone use was 1.79% in AC and 4.95% in alcoholism with odds ratio (OR) for AC 0.35 [95% CI, 0.33-0.37, p, 0.001]. As with Acamprosate, odds of treatment with Naltrexone tended to be lower in patients with AC who identified as Hispanic/Latino or had a co-existing mood disorder. Though not as commonly prescribed, overall prevalence of Disulfiram use was 0.45% in AC and 1.21% in alcoholism with odds ratio (OR) for AC 0.37 [95% CI, 0.32-0.41, p, 0.001].
Conclusion:In this population-based study, patients with AC were less likely to be treated for their alcohol use disorder with FDA-approved drugs compared to non-cirrhotics. Though incompletely understood, this may be related to the highly stigmatized nature of the disease, provider bias, and patient-related factors such as socioeconomic status and adherence. One possible explanation for naltrexone specifically, is that it is contraindicated in acute hepatitis and advanced cirrhosis. (Table )