Family Medicine Clinical Practice Guidelines: 2018 Midyear Review

John Anello; Brian Feinberg; John Heinegg; Yonah Korngold; Richard Lindsey; Cristina Wojdylo; Olivia Wong, DO

Disclosures

June 29, 2018

In This Article

Alcohol-Related Liver Disease

European Association for the Study of the Liver

Excess alcohol consumption should be addressed using pricing-based policies and regulation of availability.

Advertising and marketing of alcohol either directly or indirectly should be banned.

Primary care facilities for managing alcohol use disorder (AUD) need to be made widely available.

Screening for harmful alcohol consumption should be done by GPs and in Emergency Departments.

Screening for alcoholic liver disease (ALD) should be done in high-risk populations, such as those in alcohol rehabilitations clinics, or the harmful drinkers identified by their GP.

Patients identified through screening should undergo brief intervention and referral to a multidisciplinary team.

The term alcohol use disorder (defined by DSM-V criteria) should be used in preference to alcoholic, alcohol abuse, alcohol dependence, or risky drinker.

AUDIT (Alcohol Use Disorders Inventory Test) or AUDIT-C should be used to screen patients for AUD and dependence.

Patients with AUD should be screened for concurrent psychiatric disorders and other addictions.

Benzodiazepines should be used to treat alcohol withdrawal syndrome (AWS) but should not be prescribed beyond 10–14 days because of the potential for abuse and/or encephalopathy.

Gastroenterology/Hepatology centers should have access to services to provide effective psychosocial therapies.

Pharmacotherapy should be considered in patients with AUD and ALD.

Liver biopsy is required where there is diagnostic uncertainty, where precise staging is required, or in clinical trials.

Screening of patients with AUD should include determination of liver function tests (LFTs) and a measure of liver fibrosis.

Abstinence can be accurately monitored by measurement of ethyl glucuronide (EtG) in urine or hair.

A recent onset of jaundice in patients with excessive alcohol consumption should prompt clinicians to suspect alcoholic hepatitis (AH).

Available prognostic scores should be used to identify severe forms of AH, at risk of early mortality.

In the absence of active infection, corticosteroids (prednisolone 40 mg/day or methylprednisolone 32 mg/day) should be considered in patients with severe AH to reduce short-term mortality. However, corticosteroids do not influence medium to long-term survival.

N-acetylcysteine (for five days, intravenously) may be combined with corticosteroids in patients with severe AH.

A careful evaluation of nutritional status should be performed and patients should aim to achieve a daily energy intake ≥35–40 kcal/kg BW and 1.2–1.5 g/kg protein, and to adopt the oral route as first-line intervention.

Systematic screening for infection should be performed before initiating therapy, during corticosteroid treatment, and during the follow-up period.

Early non-response (at day seven) to corticosteroids should be identified, and strict rules for the cessation of therapy should be applied.

In case of non-response to corticosteroids, highly selected patients should be considered for early liver transplantation.

Patients with alcohol-related cirrhosis should be advised and encouraged to achieve complete abstinence from alcohol to reduce the risk of liver-related complications and mortality.

Identification and management of cofactors, including obesity and insulin resistance, malnutrition, cigarette smoking, iron overload and viral hepatitis, are recommended.

General recommendations for screening and management of complications of cirrhosis should be applied to alcoholic cirrhosis.

Liver transplantation confers a survival benefit. Liver transplantation should be considered in patients with alcoholic liver disease (classified as Child-Pugh C and/or model for end-stage liver disease (MELD) ≥15), as it confers a survival benefit.

The selection of patients with AUD should not be based on the six-month criterion alone.

The duration of abstinence before listing should depend on the degree of liver insufficiency in selected patients with a favorable addiction and psychological profile and supportive relatives.

Patients with AUD on the transplant waiting list should be checked for alcohol use by regular clinical interviews and use of laboratory tests to confirm abstinence.

A multidisciplinary approach evaluating not only medical but also psychological suitability for transplantation is mandatory before and after LT.

The integration of an addiction specialist may decrease the risk of relapse in heavy-drinking individuals.

Early LT should be proposed to a minority of patients with severe AH not responding to medical therapy after a careful selection process.

Patients should be screened regularly for cardiovascular and neurologic disease, psychiatric disorders, and neoplasms before and after LT.

Risk factors for cardiovascular disease and neoplasms, particularly cigarette smoking, should be controlled.

Early reduction in calcineurin inhibitor therapy may be considered to decrease the risk of de novo cancer after LT.

Reference

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