Management of Alcohol Use Disorder in Patients With Alcoholic Liver Disease

Abstract

Alcohol use disorder (AUD) is a common condition that develops on the background of heavy alcohol use and is characterised by the loss of control over alcohol use and a compulsion to use alcohol, often despite negative consequences. AUD is a leading cause for the resumption of alcohol use in patients with alcoholic liver disease (ALD) after treatment. Hence it is essential to screen all patients with ALD for the presence of AUD. Screening tools such as alcohol use disorders identification test (AUDIT) and AUDIT-C are used, following which the diagnosis and severity of AUD are determined using DSM-5 criteria. The management of AUD in patients with ALD is best carried out using an integrated approach involving psychiatrists and gastroenterologists/hepatologists. The treatment most often involves a combination of pharmacotherapy and psychosocial interventions which try to achieve and maintain abstinence. Although, there is limited evidence, Baclofen is the first line pharmacological agent for long-term management of AUD in patients with ALD. Intensive psychological interventions such as motivation enhancement therapy and cognitive behavioural therapy are also seen to be beneficial. Treatment retention and follow-up are vital and can positively influence outcomes.

Keywords: AA, Alcoholics Anonymous; ALD, Alcoholic Liver Disease; AMPA, α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid; AUD, Alcohol Use Disorder; AUDIT – C, Alcohol Use Disorder Identification Test – Consumption; AUDIT, Alcohol Use Disorder Identification Test; CBT, Cognitive Behavioural Therapy; CDT, Carbohydrate Deficient Transferrin; CIWA – Ar, Clinical Institute Withdrawal Assessment for Alcohol Revised; DALY, Disability Adjusted Life Years; EtG, Ethyl glucuronide; EtS, Ethyl Sulphate; FAEE, Fatty acid ethyl ester; FDA, Food and Drug Administration; GABA, Gamma-Aminobutyric acid; GGT, Gamma glutamyl transferase; HCV, Hepatitis C Virus; HE, Hepatic Encephalopathy; LT, Liver Transplantation; MCV, Mean corpuscular volume; MET, Motivation Enhancement Therapy; MI, Motivational Interviewing; NMDA, N-Methyl-d-aspartate; PEth, Phosphatidylethanol; RCT, Randomised control trial; SMS, Short Message Service; alcohol use disorder; alcoholic liver disease; diagnosis; pharmacotherapy; psychotherapy.

Figure 1

Approach to a case of AUD with ALD. Abbreviations: AUD, alcohol use disorder; AUDIT, alcohol use disorder identification test; AUDIT – C, alcohol use disorder identification test – consumption; CIWA – Ar, clinical institute withdrawal assessment for alcohol revised; MET, motivation enhancement therapy.

Figure 2

Staging of AUD and ALD and treatment. AUD, alcohol use disorder; CBT, cognitive behavioural therapy; MET, motivation enhancement therapy.

Figure 3

Psychosocial interventions based on motivation to change alcohol use.