Alcoholic liver disease diagnosis and management

ALD

1. Management of ALD & NASH

2. ALD: Principles of Management •  Steatosis –  Abstain from Alcohol •  Hepatitis –  Abstain from Alcohol –  Supportive management –  Glucocorticoids / TNF-­­α inhibition •  Cirrhosis –  Abstain from Alcohol –  Management of complications •  Portal Hypertension & Variceal bleeding •  Ascites •  Hepatic encephalopathy –  Suitability for Liver transplant

3. Alcohol spectrum   Alcohol consumption (upto 80% in many societies) •  Alcohol problem (~ 20% of all consumers) –  Alcohol abuse   Social / Interpersonal / Legal / Occupational •  Binge drinking (6+ standard drinks / occasion) –  Alcohol dependence (DSM IV criteria) •  Tolerance •  Withdrawal •  Use in larger amounts or periods than intended •  Persistent desire or unsuccessful attempts to cut down •  Time is spent obtaining alcohol •  Social, Recreational, occupational pursuits reduced •  Continued use despite knowledge of harm

4. Alcoholism is a behavioral problem

5. Presentations of alcohol problem   Acute alcohol intoxication   Sober, but with Alcohol dependence •  In Alcohol withdrawal (severe – Delirium tremens)   Hepatitis   Cirrhosis (compensated / decompensated)   Acute hepatitis in backdrop of cirrhosis

6.   Multisystem effects (Liver, Brain, Heart)

7. #1 Management of Alcohol intoxicaBon •  Stabilize vitals, consider multi drug abuse •  If aggression –  Lorazepam 2mg PO / IV stat and SOS –  Haloperidol 0.5 to 5mg PO / IM stat and q4h –  Olanzapine 2.5 to 10mg IM q2-­­6h   Evaluate for dependence   Promote abstinence •  Thiamine 50-­­100mg /day PO x 10 days

8. #2 Promoting abstinence •  Motivational interview –  Feedback to patient –  Responsibility to be taken –  Advice, rather than orders –  Menu of opBons –  Empathy –  Self-­­efficacy, support to succeed   Pre-­­contemplaBon / contemplaBon   Prevent Withdrawal symptoms

9. #3 PrevenBon / Treatment of withdrawal •  Withdrawal symptoms •  Evaluate hepaBc complicaBons •  Thiamine 50-­­100mg PO x 10 days •  Drugs used in Alcohol withdrawal –  Chlordiazepoxide •  25-­­50mg q6h and taper over 4-­­5 days –  Lorazepam •  2mg q6h and taper over 4-­­5 days –  Higher doses if delirium tremens •  Management of seizures if Hx of Delirium tremens •  PrevenBon of relapse

10. #4 PrevenBon of relapse   Remission upto 60% in one year •  Maintain remission through behavioral feedback, follow up.   Drugs used to prevent craving –  Naltrexone, Opiod inhibitor; 50-­­150mg/d PO –  Acamprosate, NMDA inhibitor; 500mg TDS PO –  Disulfiram, ALDH inhibitor; 250mg/d –  Others   Baclofen (GABA), Ondensetron, Topiramate, Prazocin

11. Management of Alcohol steato-­­ hepaBBs (ASH) •  AbsBnence from Alcohol •  SupporBve therapy –  Bed rest (avoid extreme physical acBvity) –  High caloric diet (more carbohydrates, mornings) –  IVF / anB-­­emeBcs if persistent vomikng –  Wait for recovery –  No hepatotoxic drugs

12. Severe Alcoholic steatohepaBBs (ASH) GlucocorBcoids If severe disease (Df/Maddery >32) Tab Prednisolone 40mg / day x 4 weeks followed by a slow taper TNF-­­α inhibitors

13. Pentoifylline 400mg TDS x 4 weeks Infliximab / Etarnacept (Experimental)

14. NAFLD/ NASH: Principles of Management   Steatosis / SteatohepaBBs –  Weight reducBon –  Management of Metabolic syndrome (Insulin resistance) and its consequences –  SupporBve management for hepaBBs   Cirrhosis –  Weight reducBon –  Management of Metabolic syndrome and its complicaBons –  Management of complicaBons •  Portal Hypertension & Variceal bleeding •  Ascites •  HepaBc encephalopathy –  Suitability for Liver transplant

15. Management of NASH/ NAFLD •  Structured weight loss •  A\empt at least 3-­­5% of weight loss to reverse steatosis, 10% to reverse hepaBBs •  Bariatric surgery useful, not recommended for NASH alone •  Drug therapy –  Drugs which reduce insulin resistance •  Menormin (QuesBonable benefit) •  Pioglitazone (Limited data) –  AnB-­­oxidants •  Vitamin E (Limited data)