Preventing drinking relapse in patients with alcoholic liver disease

Alcohol use disorder (AUD) is a mosaic of psychiatric and medical symptoms. Alcoholic liver disease (ALD) in its acute and chronic forms is a common clinical consequence of long-standing AUD. Patients with ALD require specialized care from pro­fessionals in addiction, gastroenterology, and psychiatry. However, medical specialists treating ALD might not regularly consider medi­cations to treat AUD because of their limited experience with the drugs or the lack of studies in patients with significant liver disease.¹ Similarly, psychiatrists might be reticent to prescribe medications for AUD, fearing that liver disease will be made worse or that they will cause other medical complications. As a result, patients with ALD might not receive care that could help treat their AUD (Box).

Given the high worldwide prevalence and morbidity of ALD,² gen­eral and subspecialized psychiatrists routinely evaluate patients with AUD in and out of the hospital. This article aims to equip a psychia­trist with:
• a practical understanding of the natural history and categorization of ALD
• basic skills to detect symptoms of ALD
• preparation to collaborate with medical colleagues in multidisciplinary management of co-occurring AUD and ALD
• a summary of the pharmacotherapeutics of AUD, with emphasis on patients with clinically apparent ALD.

Categorization and clinical features
Alcoholic liver damage encompasses a spectrum of disorders, including alcoholic fatty liver, acute alcohol hepatitis (AH), and cirrhosis following varying durations and patterns of alcohol use. Manifestations of ALD vary from asymptomatic fatty liver with minimal liver enzyme eleva­tion to severe acute AH with jaundice, coagulopathy, and high short-term mor­tality (Table 1). Symptoms seen in patients with AH include fever, abdominal pain, anorexia, jaundice, leukocytosis, and coagulopathy.³

Patients with chronic ALD often develop cirrhosis, persistent elevation of the serum aminotransferase level (even after pro­longed alcohol abstinence), signs of portal hypertension (ascites, encephalopathy, var­iceal bleeding), and profound malnutrition. The survival of ALD patients with chronic liver failure is predicted in part by a Model for End-Stage Liver Disease (MELD) score that incorporates their serum total biliru­bin level, creatinine level, and international normalized ratio. The MELD score, which ranges from 6 to 40, also is used to gauge the need for liver transplantation; most patients who have a MELD score >15 ben­efit from transplant. To definitively deter­mine the severity of ALD, a liver biopsy is required but usually is not performed in clinical practice.

All patients who drink heavily or suffer with AUD are at risk of developing AH; women and binge drinkers are particu­larly vulnerable.⁴ Liver dysfunction and malnutrition in ALD patients compromise the immune system, increasing the risk of infection. Patients hospitalized with AH have a 10% to 30% risk of inpatient mor­tality; their 1- and 2-month post-discharge survival is 50% to 65%, largely determined by whether the patient can maintain sobri­ety.⁵ Psychiatrists’ contribution to ALD treatment therefore has the potential to save lives.

Screening and detection of ALD
Because of the high mortality associated with AH and cirrhosis, symptom recogni­tion and collaborative medical and psy­chiatric management are critical (Table 2). A psychiatrist evaluating a jaun­diced patient who continues to drink should arrange urgent medical evaluation. While gathering a history, mental health providers might hear a patient refer to symptoms of gastrointestinal bleeding (vomiting blood, bloody or dark stool), painful abdominal distension, fevers, or confusion that should prompt a referral to a gastroenterologist or the emergency department. Testing for uri­nary ethyl glucuronide—a direct metabolite of ethanol that can be detected for as long as 90 hours after ethanol ingestion—is use­ful in detecting alcohol use in the past 4 or 5 days.

Medical management of ALD
Corticosteroids are a mainstay in pharma­cotherapy for severe AH. There is evidence for improved outcomes in patients with severe AH treated with prednisolone for 4 to 6 weeks.⁵ Prognostic models such as the Maddrey’s Discriminant Function, Lille Model, and the MELD score help determine the need for steroid use and identify high-risk patients. Patients with active infection or bleeding are not a candidate for steroid treatment. An experienced gastroenterolo­gist or hepatologist should initiate medical intervention after thorough evaluation.

Liver transplantation. A select group of patients with refractory liver failure are con­sidered for liver transplantation. Although transplant programs differ in their criteria for organ listing, many require patients to demonstrate at least 6 months of verified abstinence from alcohol and illicit drugs as well as adherence to a formal AUD treat­ment and rehabilitation plan. The patient’s psychological health and prognosis for sus­tained sobriety are central to candidacy for organ listing, which highlights the key role of psychiatrists.

Further considerations. Thiamine and folate often are given to patients with ALD. Abdominal imaging and screening for HIV and viral hepatitis—identified in 10% to 20% of ALD patients—is routine. Alcohol absti­nence remains central to survival because relapse increases the risk of recurrent, severe liver disease. Regrettably, many physical symptoms of liver disease, such as portal hypertension, ascites, and jaundice, can take months to improve with abstinence.