Management of alcohol use disorder in patients with cirrhosis in the setting of liver transplantation

Abstract

The prevalence of alcohol use disorder (AUD) has been steadily increasing over the past decade. In parallel, alcohol-associated liver disease (ALD) has been increasing at an alarming rate, especially among young patients. Data suggest that most patients with ALD do not receive AUD therapy. Although liver transplantation is the only curative therapy for end-stage ALD, transplant candidacy is often a matter of debate given concerns about patients being under-treated for AUD and fears of post-transplantation relapse affecting the allograft. In this Review, we discuss diagnosis, predictors and effects of relapse, behavioural therapies and pharmacotherapies, and we also propose an integrative, multidisciplinary and multimodality approach for treating AUD in patients with cirrhosis, especially in the setting of liver transplantation. Notably, this approach takes into account the utility of AUD pharmacotherapy in patients on immunosuppressive medications and those with renal impairment after liver transplantation. We also propose a comprehensive and objective definition of relapse utilizing contemporary biomarkers to guide future clinical trials. Future research using the proposed approach and definition is warranted with the goal of optimizing AUD treatment in patients with cirrhosis, the transplant selection process and post-transplantation care of patients with AUD.

Fig. 1. Patient-centred integrative care model for AUD in patients with ALD with cirrhosis (transplant candidates) and liver transplant recipients.

The figure illustrates the core contents of the multidisciplinary, multimodality approach to the management of alcohol use disorder (AUD) in patients with alcohol-associated liver disease (ALD) in the setting of cirrhotic-stage disease and after liver transplantation. The application of the various modalities listed will need to be personalized based on a patient’s clinical and psychosocial characteristics. LT, liver transplantation; NSBB, non-selective β-blocker.

Fig. 2. Considerations in the integrative care model for AUD.

Key questions to address while providing integrative care for alcohol use disorder (AUD) in patients with alcohol-associated liver disease (ALD) with cirrhosis (transplant candidates) and liver transplant (LT) recipients.

Fig. 3. Proposed care pathway for AUD in patients with ALD with cirrhosis (transplant candidates) and liver transplant recipients.

ALD, alcohol-associated liver disease; AUD, alcohol use disorder; eGFR, estimated glomerular filtration rate. *Preferred biomarker is phosphatidyl ethanol (PEth) given its ability to detect moderate to severe alcohol use up to 4 weeks prior. **FDA/EDA-approved medication for AUD. ***Topiramate should be avoided in patients with hepatic encephalopathy. This proposed algorithm has not yet been validated or tested in clinical practice, so further studies are needed to assess its broad use.