Simultaneous Management of Alcohol Use Disorder and Liver Disease: A Systematic Review and Meta-analysis

Elfeki, Mohamed A.; Abdallah, Mohamed; Leggio, Lorenzo; Singal, Ashwani K.

doi:10.1097/adm.0000000000001084

Cited by 16 publications

(17 citation statements)

References 58 publications

(127 reference statements)

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“…The 2016 review by Khan et al 11 examined only psychological interventions in patients with variable stages of liver disease. Elfeki et al 57 have also recently published their review of simultaneous management of AUD and liver disease. These reviews overlap with our analysis but included studies which we have excluded either because a diagnosis of cirrhosis was not specified, or because the study examined a post‐liver transplant population.…”

Section: Discussionmentioning

confidence: 99%

Systematic review: Interventions for alcohol use disorder in patients with cirrhosis or alcohol‐associated hepatitis

Oldroyd,

Greenham,

Martin

et al. 2023

Aliment Pharmacol Ther

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SummaryBackgroundAlcohol use is the most important factor in determining the prognosis of patients with alcohol‐related cirrhosis and alcohol‐associated hepatitis.AimTo conduct a systematic review of interventions for alcohol use disorder specific to patients with cirrhosis or alcohol‐associated hepatitis.MethodsWe searched five databases between inception and November 2022. The primary outcomes were abstinence, hepatic decompensation and mortality. We included randomised and non‐randomised studies. Risk of bias was assessed using validated tools. Where possible, meta‐analysis was performed.ResultsTwenty‐three studies met the inclusion criteria including six randomised trials and 17 non‐randomised studies of interventions. These included 104,298 patients with a mean/median age range from 44 to 65, of whom 75% were male. Interventions included psychological therapy, pharmacological therapies, specialist clinics, patient education and low alcohol drinks. Baclofen was the only intervention to demonstrate a statistically significant impact on the primary outcomes in a randomised trial (abstinence OR: 6.3, 95% CI: 2.4–16.1). Three non‐randomised studies reported reductions in episodes of hepatic decompensation that were significant in multivariate models. This was in response to psychological therapy, use of any pharmacotherapy, and use of any treatment. A meta‐analysis of non‐randomised studies that examined the impact of psychological therapies revealed statistically non‐significant improvements in abstinence (4 studies, OR: 1.87, 95% CI: 0.38–9.23) and mortality (4 studies, OR: 0.47, 95% CI: 0.12–1.77).ConclusionsBaclofen is the only intervention with randomised trial evidence for significant benefit in patients with cirrhosis. Non‐randomised studies also point to non‐pharmaceutical interventions possibly improving clinical outcomes.

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Section: Discussionmentioning

confidence: 99%

Systematic review: Interventions for alcohol use disorder in patients with cirrhosis or alcohol‐associated hepatitis

Oldroyd,

Greenham,

Martin

et al. 2023

Aliment Pharmacol Ther

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“…Only 14% of veterans with ALD, however, received any AUD treatment, with <1% receiving pharmacotherapy. In a systematic review of 13 studies (5 of which were randomized controlled) on 1,945 patients (137), abstinence rates, however, were higher in a randomized controlled study with an integrated multidisciplinary care model with hepatologists and addiction specialists in a colocated clinic compared with usual care of AUD (74% vs 49%, P = 0.02) (138). In another meta-analysis of 6 studies on 649 LT recipients for ALD, an integrated care model compared with standard follow-up by only hepatology in a transplant clinic was associated with a lower rate of relapse to alcohol and long-term patient mortality with odds ratios of 0.56 (95% CI 0.36–0.87) and 0.29 (95% CI 0.08–0.99), respectively (139).…”

Section: Management Of Aldmentioning

confidence: 99%

“…In a prospective, noncontrolled pilot program assessing a multidisciplinary care model for AUD in the pretransplant and posttransplant care of patients with <6 months of sobriety before LT, only 3 of 44 patients relapsed to alcohol use (mean follow-up period = 339 days) (271). In a meta-analysis of 6 studies on 649 patients transplanted for ALD, a multidisciplinary integrated care model compared with follow-up by hepatology alone in a transplant clinic was associated with lower rates of relapse to alcohol use and long-term patient mortality, with the respective odds ratio of 0.56 (95% CI 0.36–0.87) and 0.29 (95% CI 0.08–0.99) (137). Use of medications to reduce cravings may be considered, although there are no studies of the efficacy of medication-associated therapy in liver transplant recipients.…”

Section: Ltmentioning

confidence: 99%

ACG Clinical Guideline: Alcohol-Associated Liver Disease

Jophlin,

Singal,

Bataller

et al. 2023

Am J Gastroenterol

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Alcohol-associated liver disease (ALD) is the most common cause of advanced hepatic disease and frequent indication for liver transplantation worldwide. With harmful alcohol use as the primary risk factor, increasing alcohol use over the past decade has resulted in rapid growth of the ALD-related healthcare burden. The spectrum of ALD ranges from early asymptomatic liver injury to advanced disease with decompensation and portal hypertension. Compared with those with other etiologies of liver disease, patients with ALD progress faster and more often present at an advanced stage. A unique phenotype of advanced disease is alcohol-associated hepatitis (AH) presenting with rapid onset or worsening of jaundice, and acute on chronic liver failure in severe forms conveying a 1-month mortality risk of 20%–50%. The model for end stage disease score is the most accurate score to stratify AH severity (>20 defined as severe disease). Corticosteroids are currently the only available therapeutic with proven efficacy for patients with severe AH, providing survival benefit at 1 month in 50%–60% of patients. Abstinence of alcohol use, a crucial determinant of long-term outcomes, is challenging to achieve in ALD patients with concurrent alcohol use disorder (AUD). As patients with ALD are rarely treated for AUD, strategies are needed to overcome barriers to AUD treatment in patients with ALD and to promote a multidisciplinary integrated care model with hepatology, addiction medicine providers, and social workers to comprehensively manage the dual pathologies of liver disease and of AUD. Liver transplantation, a definitive treatment option in patients with advanced cirrhosis, should be considered in selected patients with AH, who are unresponsive to medical therapy and have a low risk of relapse to posttransplant alcohol use. Level of evidence and strength of recommendations were evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations system. This guideline was developed under the American College of Gastroenterology Practice Parameters Committee.

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“…Previous publications in the hepatology literature have discussed the need for integrated addiction medicine and hepatology care 9,10 . A recent meta‐analysis that included 20 studies concluded that both simultaneous and integrated care of AUD and ALD results in improved outcomes 11 . One such published model is the University of Michigan Alcohol‐Related Liver Disease Clinic.…”

Section: Need For Integrated Carementioning

confidence: 99%

“…9,10 A recent meta-analysis that included 20 studies concluded that both simultaneous and integrated care of AUD and ALD results in improved outcomes. 11 One such published model is the University of Michigan Alcohol-Related Liver Disease Clinic. This model integrates transplant hepatology, consultliaison psychiatry, addiction psychology, addiction social work, and hepatology nursing into a single, co-located clinic where patients spend 1-half day with each of these specialists.…”

mentioning

confidence: 99%

Integrated care models for co‐occurring alcohol use disorders and alcohol‐associated liver disease in rural communities: Telehealth considerations and opportunities

Osman,

Koneru,

Weber

2023

The Journal of Rural Health

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Alcohol use disorders (AUD) and alcohol‐associated liver disease (ALD) have growing impacts on public health, yet many do not receive evidence‐based care. People with co‐occurring AUD and ALD, especially those in rural communities with less access to specialty care, are most in need of novel integrated care models. The use of telehealth to facilitate co‐location within an integrated care model may help to improve access to AUD and ALD care while reducing barriers and improving recovery outcomes for both the substance use disorder and liver disease.

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Simultaneous Management of Alcohol Use Disorder and Liver Disease: A Systematic Review and Meta-analysis

Cited by 16 publications

References 58 publications

Systematic review: Interventions for alcohol use disorder in patients with cirrhosis or alcohol‐associated hepatitis

Systematic review: Interventions for alcohol use disorder in patients with cirrhosis or alcohol‐associated hepatitis

ACG Clinical Guideline: Alcohol-Associated Liver Disease

Integrated care models for co‐occurring alcohol use disorders and alcohol‐associated liver disease in rural communities: Telehealth considerations and opportunities

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