Best Practices for Identifying and Treating Alcohol-associated Hepatitis Include Treatment of Alcohol Use Disorder

Alcohol accounts for approximately half of deaths from liver disease worldwide, and deaths from alcohol-associated liver disease have been increasing in the US. Researchers recently summarized the etiology and treatment for alcohol-associated hepatitis, which is characterized by moderately rapid onset of jaundice, malaise, and decompensated liver disease that can be accompanied by either bacterial infection or systemic anti-inflammatory response and multi-organ failure.

  • The 3-month mortality rate for alcohol-associated hepatitis among hospitalized patients is 20–50 percent.
  • Although it occurs among people with heavy drinking, there are likely a number of modifying social, environmental, genetic, and epigenetic factors that affect the likelihood and severity of illness. There is greater incidence among women and people of Hispanic origin.
  • Criteria for alcohol-associated hepatitis include:
    • onset of jaundice within the previous 8 weeks;
    • consumption of >3 drinks (~40 g alcohol) per day for women and >4 drinks (~50–60 g) per day for men for >6 months with <60 days of abstinence before the onset of jaundice;
    • a total serum bilirubin level of >3 mg per deciliter (>50 μmol per liter), an aspartate aminotransferase (AST) level of >50 IU per liter, and a ratio of AST to alanine aminotransferase of >1.5 with both values <400 IU per liter; and
    • no other liver diseases such as drug-induced liver injury and ischemic hepatitis.
  • The principal prognostic feature for long-term survival is avoidance of alcohol use. Glucocorticoid administration in severe cases can reduce short-term but not long-term mortality rates. Early transplantation in selected patients reduces mortality.
  • Alcohol use disorder is often under-treated among patients with alcohol-associated hepatitis.

Comments: Alcohol-associated hepatitis is a severe form of liver disease caused by heavy alcohol use; the main prognostic factor is the reduction or cessation of subsequent alcohol use. As such, management of alcohol-associated hepatitis should focus on addiction treatment, including the use of counseling and appropriate use of medications to treat alcohol use disorder.

Timothy S. Naimi, MD, MPH

Reference: Bataller R, Arab JP, Shah VH. Alcohol-associated hepatitisN Engl J Med. 2022;387(26):2436–2448.

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