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Lee BP, Witkiewitz K, Mellinger J, Anania FA, Bataller R, Cotter TG, Curtis B, Dasarathy S, DeMartini KS, Diamond I, Diazgranados N, DiMartini AF, Falk DE, Fernandez AC, German MN, Kamath PS, Kidwell KM, Leggio L, Litten R, Louvet A, Lucey MR, McCaul ME, Sanyal AJ, Singal AK, Sussman NL, Terrault NA, Thursz MR, Verna EC, Radaeva S, Nagy LE, Mitchell MC. Designing clinical trials to address alcohol use and alcohol-associated liver disease: an expert panel Consensus Statement. Nat Rev Gastroenterol Hepatol 2024:10.1038/s41575-024-00936-x. [PMID: 38849555 DOI: 10.1038/s41575-024-00936-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2024] [Indexed: 06/09/2024]
Abstract
Most patients with alcohol-associated liver disease (ALD) engage in heavy drinking defined as 4 or more drinks per day (56 g) or 8 (112 g) or more drinks per week for women and 5 or more drinks per day (70 g) or 15 (210 g) or more drinks per week for men. Although abstinence from alcohol after diagnosis of ALD improves life expectancy and reduces the risk of decompensation of liver disease, few studies have evaluated whether treatment of alcohol use disorders will reduce progression of liver disease and improve liver-related outcomes. In November 2021, the National Institute of Alcohol Abuse and Alcoholism commissioned a task force that included hepatologists, addiction medicine specialists, statisticians, clinical trialists and members of regulatory agencies to develop recommendations for the design and conduct of clinical trials to evaluate the effect of alcohol use, particularly treatment to reduce or eliminate alcohol use in patients with ALD. The task force conducted extensive reviews of relevant literature on alcohol use disorders and ALD. Findings were presented at one in-person meeting and discussed over the next 16 months to develop the final recommendations. As few clinical trials directly address this topic, the 28 recommendations approved by all members of the task force represent a consensus of expert opinions.
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Affiliation(s)
- Brian P Lee
- Division of Gastroenterology and Liver Diseases, University of Southern California Keck School of Medicine and Institute for Addiction Science, University of Southern California, Los Angeles, CA, USA
| | - Katie Witkiewitz
- Center on Alcohol, Substance use and Addictions, University of New Mexico, Albuquerque, NM, USA
| | - Jessica Mellinger
- Department of Internal Medicine, Department of Psychiatry, Michigan Medicine, Ann Arbor, MI, USA
| | - Frank A Anania
- Division of Hepatology and Nutrition, US Food and Drug Administration, Silver Spring, MD, USA
| | - Ramon Bataller
- Liver Unit, Hospital Clinic, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Thomas G Cotter
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Brenda Curtis
- Technology and Translational Research Unit, Translational Addiction Medicine Branch, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, USA
| | - Srinivasan Dasarathy
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Kelly S DeMartini
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | | | - Nancy Diazgranados
- Office of the Clinical Director, National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | - Andrea F DiMartini
- Departments of Psychiatry and Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Daniel E Falk
- Medications Development Branch, National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | | | - Margarita N German
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Kelley M Kidwell
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Lorenzo Leggio
- Clinical Psychoneuroendocrinology and Neuropsychopharmacology Section, Translational Addiction Medicine Branch, National Institute on Drug Abuse Intramural Research Program and National Institute on Alcohol Abuse and Alcoholism Division of Intramural Clinical and Biological Research, National Institutes of Health, Baltimore, MD, USA
| | - Raye Litten
- Division of Treatment and Recovery, National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | - Alexandre Louvet
- Service des maladies de l'appareil digestif, University Hospital of Lille, Lille, France
- Unité INSERM INFINITE, Lille, France
| | - Michael R Lucey
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Mary E McCaul
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Arun J Sanyal
- Stravitz-Sanyal Institute for Liver Disease and Metabolic Health, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Ashwani K Singal
- Department of Medicine, Division of Gastroenterology Hepatology and Nutrition, University of Louisville School of Medicine, Louisville, KY, USA
- Department of Medicine, Robley Rex VA Medical Center, Louisville, KY, USA
| | - Norman L Sussman
- DURECT Corporation, Cupertino, CA, USA
- Baylor College of Medicine, Houston, TX, USA
| | - Norah A Terrault
- Division of Gastroenterology and Liver Diseases, University of Southern California Keck School of Medicine and Institute for Addiction Science, University of Southern California, Los Angeles, CA, USA
| | - Mark R Thursz
- Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Elizabeth C Verna
- Division of Digestive and Liver Diseases, Columbia University, New York, NY, USA
| | - Svetlana Radaeva
- Svetlana Radaeva, Division of Metabolism and Health Effects, National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | - Laura E Nagy
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Mack C Mitchell
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Mellinger JL, Winder GS, Fernandez AC, Asefah H, Zikmund-Fisher BJ. Critical misconceptions and knowledge gaps regarding alcohol cessation and risk of relapse in alcohol-related liver disease patients: A qualitative mental models study. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 161:209292. [PMID: 38364995 DOI: 10.1016/j.josat.2024.209292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 09/27/2023] [Accepted: 01/11/2024] [Indexed: 02/18/2024]
Abstract
INTRODUCTION Despite the mortality benefits of alcohol cessation and alcohol treatment, few patients with alcohol-related liver disease (ALD) get such treatment. To understand reasons for low treatment rates, we performed a qualitative mental models study to explore how ALD patients understand factors influencing alcohol cessation, relapse and their liver health. METHODS Using a mental models framework, we interviewed experts in alcohol use disorder (AUD) and ALD to determine factors influencing alcohol cessation, risk of relapse and liver health. An expert influence diagram was constructed and used to develop a patient interview guide. We recruited participants with ALD enrolled in hepatology or transplant clinics at a single tertiary-care center. We conducted interviews either face-to-face or by phone, per participant preference. We transcribed all interviews verbatim and analyzed them using combined deductive coding schema based on both the interview guide and emergent coding. RESULTS 25 (10 women, 15 men) participants with a mean age of 57 years completed interviews. 68 % had decompensated cirrhosis. Major omissions included gender (as a factor in alcohol use or liver disease) and the influence of benzodiazepines/opioids on relapse. Misconceptions were common, in particular the idea that the absence of urges to drink meant participants were safe from relapse. Conceptual differences from the expert model emerged as well. Participants tended to view the self as primary and the only thing that could influence relapse in many cases, resulting in a linear mental model with few nodes influencing alcohol cessation. Participants' risky drinking signals (i.e., elevated liver enzymes) differed from known definitions of hazardous or high-risk drinking, which largely emphasize dose of alcohol consumed irrespective of consequences. Finally, participants sometimes viewed stopping on one's own as the primary means of stopping alcohol use, not recognizing the many other nodes in the influence diagram impacting ability to stop alcohol. CONCLUSION Patients with ALD had critical misconceptions, omissions, and conceptual reorganizations in their mental models of the ability to stop alcohol use. Attention to these differences may allow clinicians and researchers to craft more impactful interventions to improve rates of alcohol abstinence and AUD treatment engagement.
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Affiliation(s)
- Jessica L Mellinger
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, United States of America; Department of Psychiatry, Michigan Medicine, Ann Arbor, MI, United States of America.
| | - Gerald Scott Winder
- Department of Psychiatry, Michigan Medicine, Ann Arbor, MI, United States of America; University of Michigan Department of Surgery, Michigan Medicine, Ann Arbor, MI, United States of America; University of Michigan Department of Neurology, Michigan Medicine, Ann Arbor, MI, United States of America
| | - Anne C Fernandez
- Department of Psychiatry, Michigan Medicine, Ann Arbor, MI, United States of America; University of Michigan Addiction Treatment Service, Michigan Medicine, Ann Arbor, MI, United States of America
| | - Haila Asefah
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, United States of America
| | - Brian J Zikmund-Fisher
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, United States of America; Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, United States of America
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Anouti A, Seif El Dahan K, Rich NE, Louissaint J, Lee WM, Lieber SR, Arab JP, Zhang BY, Patel MJ, Thimphittaya C, Díaz LA, Gregory DL, Kozlitina J, VanWagner LB, King AC, Mitchell MC, Singal AG, Cotter TG. Racial and ethnic disparities in alcohol-associated liver disease in the United States: A systematic review and meta-analysis. Hepatol Commun 2024; 8:e0409. [PMID: 38497931 PMCID: PMC10948135 DOI: 10.1097/hc9.0000000000000409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 11/28/2023] [Indexed: 03/19/2024] Open
Abstract
BACKGROUND Alcohol-associated liver disease (ALD), encompassing alcohol-associated hepatitis and alcohol-associated cirrhosis, is rising in the United States. Racial and ethnic disparities are evident within ALD; however, the precise nature of these disparities is poorly defined. METHODS We conducted a search of the PubMed/MEDLINE and EMBASE databases to identify studies published from inception through September 2023 that reported ALD incidence, prevalence, and mortality within the United States, stratified by race and ethnicity. We calculated pooled prevalence and incidence by race and ethnicity, including risk ratios and ORs for ALD pooled prevalence and alcohol-associated hepatitis/alcohol-associated cirrhosis pooled proportions, and OR for ALD mortality using the DerSimonian and Laird method for random-effect models. RESULTS We identified 25 relevant studies (16 for quantitative meta-analysis), comprising 76,867,544 patients. ALD prevalence was highest in Hispanic (4.5%), followed by White (3.1%) and Black (1.4%) individuals. Pooled risk ratios of ALD prevalence were 1.64 (95% CI: 1.12-2.39) for Hispanic and 0.59 (95% CI: 0.35-0.87) for Black compared to White individuals. Mortality among those with ALD did not significantly differ between White and Hispanic (OR: 1.54, 95% CI: 0.9-2.5; I2=0%), Black (OR: 1.2, 95% CI: 0.8-1.6; I2=0%), or Native American (OR: 2.41, 95% CI: 0.9-2.9) individuals, while there was a significant difference between White and Asian (OR: 0.1; 95% CI: 0.03-0.5) individuals. Most data were cross-sectional and assessed to be of poor or fair quality. CONCLUSIONS Differences were observed in ALD epidemiology, including higher prevalence among Hispanic and lower prevalence among Black individuals, although there were smaller differences in ALD mortality. Differences in ALD prevalence and prognosis remain poorly defined based on existing data, highlighting a need for higher-quality epidemiological studies in this area.
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Affiliation(s)
- Ahmad Anouti
- Department of Internal Medicine, Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Karim Seif El Dahan
- Department of Internal Medicine, Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Nicole E. Rich
- Department of Internal Medicine, Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Jeremy Louissaint
- Department of Internal Medicine, Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas, USA
| | - William M. Lee
- Department of Internal Medicine, Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Sarah R. Lieber
- Department of Internal Medicine, Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Juan Pablo Arab
- Department of Medicine, Division of Gastroenterology, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Bill Y. Zhang
- University of Texas Southwestern Medical School, Dallas, Texas, USA
| | - Mausam J. Patel
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Chanattha Thimphittaya
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Luis Antonio Díaz
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Dyanna L. Gregory
- Department of Internal Medicine, Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Julia Kozlitina
- Department of Internal Medicine, The Eugene McDermott Center for Human Growth and Development, University of Texas Southwestern, Dallas, Texas, USA
| | - Lisa B. VanWagner
- Department of Internal Medicine, Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Andrea C. King
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Comprehensive Cancer Center, Chicago, Illinois, USA
| | - Mack C. Mitchell
- Department of Internal Medicine, Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Amit G. Singal
- Department of Internal Medicine, Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Thomas G. Cotter
- Department of Internal Medicine, Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas, USA
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Lim WH, Tay P, Ng CH, Tan DJH, Ong C, Koh JH, Teng M, Chee D, Wong ZY, Kawaguchi T, Takahashi H, Muthiah M, Tan EXX, Wijarnpreecha K, Lee GH, Noureddin M, Lee BP, Mathurin P, Loomba R, Huang DQ. Meta-analysis: Prevalence and impact of alcohol abstinence in alcohol-associated cirrhosis. Aliment Pharmacol Ther 2024; 59:730-741. [PMID: 38303565 DOI: 10.1111/apt.17888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 11/21/2023] [Accepted: 01/14/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND Although alcohol abstinence may be an effective intervention for alcohol-associated cirrhosis, its association with prognosis has not been systematically assessed or quantified. AIMS To determine the prevalence of alcohol abstinence, factors associated with alcohol abstinence and the impact of abstinence on morbidity and overall survival in people with alcohol-associated cirrhosis. METHODS We searched Medline and Embase from inception to 15 April 2023 for prospective and retrospective cohort studies describing alcohol abstinence in people with known alcohol-associated cirrhosis. Meta-analysis of proportions for pooled estimates was performed. The method of inverse variance, employing a random-effects model, was used to pool the hazard ratio (HR) comparing outcomes of abstinent against non-abstinent individuals with alcohol-associated cirrhosis. RESULTS We included 19 studies involving 18,833 people with alcohol-associated cirrhosis. The prevalence of alcohol abstinence was 53.8% (CI: 44.6%-62.7%). Over a mean follow-up duration of 48.6 months, individuals who continued to consume alcohol had significantly lower overall survival compared to those who were abstinent (HR: 0.611, 95% CI: 0.506-0.738). These findings remained consistent in sensitivity/subgroup analysis for the presence of decompensation, study design and studies that assessed abstinence throughout follow-up. Alcohol abstinence was associated with a significantly lower risk of hepatic decompensation (HR: 0.612, 95% CI: 0.473-0.792). CONCLUSIONS Alcohol abstinence is associated with substantial improvement in overall survival in alcohol-associated cirrhosis. However, only half of the individuals with known alcohol-associated cirrhosis are abstinent.
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Affiliation(s)
- Wen Hui Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Phoebe Tay
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Cheng Han Ng
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Darren Jun Hao Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Christen Ong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Jia Hong Koh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
| | - Margaret Teng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
| | - Douglas Chee
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Zhen Yu Wong
- School of Medicine, International Medical University, Kuala Lumpur, Malaysia
| | - Takumi Kawaguchi
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | | | - Mark Muthiah
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
| | - Eunice X X Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
| | - Karn Wijarnpreecha
- Department of Internal Medicine, Bassett Medical Center, Cooperstown, New York, USA
| | - Guan Huei Lee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
| | | | - Brian P Lee
- Division of Gastroenterology and Liver Diseases, University of Southern California, Los Angeles, California, USA
| | - Philippe Mathurin
- Service des Maladies de l'appareil Digestif, Hôpital Huriez, CHU, Lille, France
| | - Rohit Loomba
- NAFLD Research Center, Division of Gastroenterology, University of California at San Diego, La Jolla, California, USA
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Daniel Q Huang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
- NAFLD Research Center, Division of Gastroenterology, University of California at San Diego, La Jolla, California, USA
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Mellinger JL, Medley S, Kidwell KM, Asefah H, Winder GS, Fernandez AC, Lok ASF, Blow F. Improving alcohol treatment engagement using integrated behavioral interventions in alcohol-associated liver disease: A randomized pilot trial. Hepatol Commun 2023; 7:e0181. [PMID: 37708435 PMCID: PMC10503679 DOI: 10.1097/hc9.0000000000000181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 04/24/2023] [Indexed: 09/16/2023] Open
Abstract
INTRODUCTION Alcohol cessation improves mortality in alcohol-associated liver disease (ALD), but few ALD patients will engage in treatment. We aimed to demonstrate the feasibility and acceptability of a mobile health intervention to increase alcohol use disorder (AUD) treatment among ALD patients. METHODS We conducted a pilot randomized controlled trial (September 2020 to June 2022) at a single tertiary care center in adults with any stage of ALD, past 6-month drinking, and no past-month AUD treatment. Sixty participants were randomized 1:1 to a mobile health application designed to increase AUD treatment engagement through preference elicitation and matching to treatment and misconception correction. Controls received enhanced usual care. The primary outcomes were feasibility (recruitment and retention rates) and acceptability. Exploratory outcomes were AUD treatment engagement and alcohol use, measured by Timeline Followback. Outcomes were measured at 3 and 6 months. RESULTS Baseline characteristics were balanced. The recruitment rate was 46%. Retention was 65% at 6 months. The intervention was highly acceptable to participants (91% were mostly/very satisfied; 95% felt that the intervention matched them well to AUD treatment). Secondary outcomes showed increased AUD treatment at 6 months in the intervention group (intent-to-treat: 27.3% vs. 13.3%, OR 2.3, 95% CI, 0.61-8.76). There was a trend toward a 1-level or greater reduction in World Health Organization (WHO) drinking risk levels in the intervention group (OR 2.25, 95% CI, 0.51-9.97). CONCLUSIONS A mobile health intervention for AUD treatment engagement was highly feasible, acceptable, and produced promising early outcomes, with improved AUD treatment engagement and alcohol reduction in ALD patients.
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Affiliation(s)
- Jessica L. Mellinger
- Michigan Medicine, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Ann Arbor, Michigan, United States
- Michigan Medicine, Department of Psychiatry, Ann Arbor, Michigan, United States
| | - Sarah Medley
- Department of Biostatistics, University of Michigan, School of Public Health, Ann Arbor, Michigan, United States
| | - Kelley M. Kidwell
- Department of Biostatistics, University of Michigan, School of Public Health, Ann Arbor, Michigan, United States
| | - Haila Asefah
- Michigan Medicine, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Ann Arbor, Michigan, United States
| | - G. Scott Winder
- Michigan Medicine, Department of Psychiatry, Ann Arbor, Michigan, United States
- Department of Surgery Michigan Medicine, Ann Arbor, Michigan, United States
- Department of Neurology Michigan Medicine, Ann Arbor, Michigan, United States
| | - Anne C. Fernandez
- Michigan Medicine, Department of Psychiatry, Ann Arbor, Michigan, United States
| | - Anna S. F. Lok
- Michigan Medicine, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Ann Arbor, Michigan, United States
| | - Fred Blow
- Michigan Medicine, Department of Psychiatry, Ann Arbor, Michigan, United States
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Pais R, Cariou B, Noureddin M, Francque S, Schattenberg JM, Abdelmalek MF, Lalazar G, Varma S, Dietrich J, Miller V, Sanyal A, Ratziu V. A proposal from the liver forum for the management of comorbidities in non-alcoholic steatohepatitis therapeutic trials. J Hepatol 2023; 79:829-841. [PMID: 37001695 DOI: 10.1016/j.jhep.2023.03.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 02/08/2023] [Accepted: 03/13/2023] [Indexed: 06/19/2023]
Abstract
The current document has been developed by the Liver Forum who mandated the NAFLD-Associated Comorbidities Working Group - a multistakeholder group comprised of experts from academic medicine, industry and patient associations - to identify aspects of diverse comorbidities frequently associated with non-alcoholic steatohepatitis (NASH) that can interfere with the conduct of therapeutic trials and, in particular, impact efficacy and safety results. The objective of this paper is to propose guidance for the management of relevant comorbidities in both candidates and actual participants in NASH therapeutic trials. We relied on specific guidelines from scientific societies, when available, but adapted them to the particulars of NASH trials with the aim of addressing multiple interacting requirements such as maintaining patient safety, reaching holistic therapeutic objectives, minimising confounding effects on efficacy and safety of investigational agents and allowing for trial completion. We divided the field of action into: first, analysis and stabilisation of the patient's condition before inclusion in the trial and, second, management of comorbidities during trial conduct. For the former, we discussed the concept of acceptable vs. optimal control of comorbidities, defined metabolic and ponderal stability prior to randomisation and weighed the pros and cons of a run-in period. For the latter, we analysed non-hepatological comorbid conditions for changes or acute events possibly occurring during the trial, including changes in alcohol consumption, in order to detail when specific interventions are necessary and how best to manage concomitant drug intake in line with methodological constraints. These recommendations are intended to act as a guide for clinical trialists and are open to further refinement when additional data become available.
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Affiliation(s)
- Raluca Pais
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Institute of Cardiometabolism and Nutrition, France; Centre de Recherche Saint Antoine, INSERM UMRS_938 Paris, France
| | - Bertrand Cariou
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du Thorax, F-44000 Nantes, France
| | | | - Sven Francque
- Department of Gastroenterology Hepatology, Antwerp University Hospital, Drie Eikenstraat 655, B-2650 Edegem, Belgium; InflaMed Centre of Excellence, Laboratory for Experimental Medicine and Paediatrics, Translational Sciences in Inflammation and Immunology, Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, B-2610 Wilrijk, Belgium European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Belgium
| | - Jörn M Schattenberg
- Metabolic Liver Research Program, I. Department of Medicine, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Manal F Abdelmalek
- Division of Gastroenterology and Hepatology, Duke University, Durham, NC, USA
| | - Gadi Lalazar
- Liver Unit, Digestive Disease Institute, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Sharat Varma
- Novo Nordisk A/S, Vandtårnsvej 108-110, 2860 Søborg Denmark
| | - Julie Dietrich
- GENFIT, Parc Eurasanté 885, Avenue Eugène Avinée, 59120, Loos, France
| | - Veronica Miller
- Forum for Collaborative Research, University of California Berkeley School of Public Health, Washington D.C., USA
| | - Arun Sanyal
- Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Vlad Ratziu
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Institute of Cardiometabolism and Nutrition, France; INSERM UMRS 1138 CRC, Paris, France.
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7
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Mellinger JL, Fernandez AC, Winder GS. Management of alcohol use disorder in patients with chronic liver disease. Hepatol Commun 2023; 7:e00145. [PMID: 37314739 DOI: 10.1097/hc9.0000000000000145] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 03/15/2023] [Indexed: 06/15/2023] Open
Abstract
Alcohol use disorder (AUD) rates have risen dramatically in the United States, resulting in increasing rates of alcohol-associated liver disease (ALD), but many patients struggle to access alcohol use treatment. AUD treatment improves outcomes, including mortality, and represents the most urgent means by which care can be improved for those with liver disease (including ALD and others) and AUD. AUD care for those with liver disease involves 3 steps: detecting alcohol use, diagnosing AUD, and directing patients to alcohol treatment. Detecting alcohol use can involve questioning during the clinical interview, the use of standardized alcohol use surveys, and alcohol biomarkers. Identifying and diagnosing AUD are interview-based processes that should ideally be performed by a trained addiction professional, but nonaddiction clinicians can use surveys to determine the severity of hazardous drinking. Referral to formal AUD treatment should be made, especially where more severe AUD is suspected or identified. Therapeutic modalities are numerous and include different forms of one-on-one psychotherapy, such as motivational enhancement therapy or cognitive behavior therapy, group therapy, community mutual aid societies (such as Alcoholics Anonymous), inpatient addiction treatment, and relapse prevention medications. Finally, integrated care approaches that build strong relationships between addiction professionals and hepatologists or medical providers caring for those with liver disease are crucial to improving care for this population.
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Affiliation(s)
- Jessica L Mellinger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
- Department of Psychiatry, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Anne C Fernandez
- Department of Psychiatry, Michigan Medicine, Ann Arbor, Michigan, USA
| | - G Scott Winder
- Department of Psychiatry, Michigan Medicine, Ann Arbor, Michigan, USA
- Department of Surgery, Michigan Medicine, Ann Arbor, Michigan, USA
- Department of Neurology, Michigan Medicine, Ann Arbor, Michigan, USA
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8
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Anouti A, Mellinger JL. The Changing Epidemiology of Alcohol-Associated Liver Disease: Gender, Race, and Risk Factors. Semin Liver Dis 2023; 43:50-59. [PMID: 36529138 DOI: 10.1055/a-2000-6680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Cases of alcohol-associated liver disease (ALD) are increasing at a steady rate in the United States with more patients presenting with alcohol-associated hepatitis and alcohol-associated cirrhosis. While alcohol use has increased across many demographic groups, women are suffering from a greater increase in alcohol use disorder (AUD), and are at a greater risk of ALD due to pathophysiological differences which include absorption of alcohol, first pass metabolism, and hormonal differences. Differences across race have also been found with Native Americans and Hispanics suffering from some of the largest increases in ALD rates. Younger adults are heavily impacted by rising rates of both AUD and ALD. Comorbidities such as obesity and NASH have been shown to augment the deleterious effects of AUD and ALD, resulting in more advanced liver disease. Finally, COVID-19 and policies related to the pandemic have resulted in increased AUD across many cohorts, which have resulted in marked increases in ALD. In conclusion, ALD rates are rising, with young people and women particularly impacted.
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Affiliation(s)
- Ahmad Anouti
- Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jessica L Mellinger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan
- Department of Psychiatry, University of Michigan Health System, Ann Arbor, Michigan
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9
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Lee BP, Roth N, Rao P, Im GY, Vogel AS, Hasbun J, Roth Y, Shenoy A, Arvelakis A, Ford L, Dawe I, Schiano TD, Davis JP, Rice JP, Eswaran S, Weinberg E, Han H, Hsu C, Fix OK, Maddur H, Ghobrial RM, Therapondos G, Dilkina B, Terrault NA. Artificial intelligence to identify harmful alcohol use after early liver transplant for alcohol-associated hepatitis. Am J Transplant 2022; 22:1834-1841. [PMID: 35416409 PMCID: PMC9541176 DOI: 10.1111/ajt.17059] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 03/13/2022] [Accepted: 04/10/2022] [Indexed: 01/25/2023]
Abstract
Early liver transplantation (LT) for alcohol-associated hepatitis (AH) is the fastest growing indication for LT, but prediction of harmful alcohol use post-LT remains limited. Among 10 ACCELERATE-AH centers, we examined psychosocial evaluations from consecutive LT recipients for AH from 2006 to 2017. A multidisciplinary panel used content analysis to develop a maximal list of psychosocial variables. We developed an artificial intelligence model to predict post-LT harmful alcohol use. The cohort included training (N = 91 among 8 centers) and external validation (N = 25 among 2 centers) sets, with median follow-up of 4.4 (IQR 3.0-6.0) years post-LT. In the training set, AUC was 0.930 (95%CI 0.862-0.998) with positive predictive value of 0.891 (95%CI 0.620-1.000), internally validated through fivefold cross-validation. In the external validation set, AUC was 0.692 (95%CI 0.666-0.718) with positive predictive value of 0.82 (95%CI 0.625-1.000). The model identified specific variables related to social support and substance use as highly important to predict post-LT harmful alcohol use. We retrospectively developed and validated a model that identified psychosocial profiles at LT predicting harmful alcohol use post-LT for AH. This preliminary model may inform selection and post-LT management for AH and warrants prospective evaluation in larger studies among all alcohol-associated liver disease being considered for early LT.
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Affiliation(s)
- Brian P. Lee
- University of Southern California Keck School of MedicineLos AngelesCaliforniaUSA
| | | | - Prathik Rao
- University of Southern California Keck School of MedicineLos AngelesCaliforniaUSA
| | - Gene Y. Im
- Mount Sinai Icahn School of MedicineNew York CityNew YorkUSA
| | | | - Johann Hasbun
- New York University Grossman School of MedicineNew York CityNew YorkUSA
| | - Yoel Roth
- Twitter IncSan FranciscoCaliforniaUSA
| | - Akhil Shenoy
- Columbia University Vagelos College of Physicians and SurgeonsNew York CityNew YorkUSA
| | | | - Laura Ford
- Mount Sinai Icahn School of MedicineNew York CityNew YorkUSA
| | - Inga Dawe
- Mount Sinai Icahn School of MedicineNew York CityNew YorkUSA
| | | | - Jordan P. Davis
- University of Southern California Keck School of MedicineLos AngelesCaliforniaUSA
| | | | | | - Ethan Weinberg
- University of Pennsylvania Perelman School of MedicinePhiladelphiaPennsylvaniaUSA
| | - Hyosun Han
- University of Southern California Keck School of MedicineLos AngelesCaliforniaUSA
| | - Christine Hsu
- Georgetown School of MedicineWashingtonDistrict of ColumbiaUSA
| | - Oren K. Fix
- University of North Carolina at Chapel Hill School of MedicineChapel HillNorth CarolinaUSA
| | - Haripriya Maddur
- Northwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | | | | | - Bistra Dilkina
- University of Southern California Keck School of MedicineLos AngelesCaliforniaUSA
| | - Norah A. Terrault
- University of Southern California Keck School of MedicineLos AngelesCaliforniaUSA
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10
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Singal AK, Kwo P, Kwong A, Liangpunsakul S, Louvet A, Mandrekar P, McClain C, Mellinger J, Szabo G, Terrault N, Thursz M, Winder GS, Kim WR, Shah VH. Research methodologies to address clinical unmet needs and challenges in alcohol-associated liver disease. Hepatology 2022; 75:1026-1037. [PMID: 34496071 PMCID: PMC9235468 DOI: 10.1002/hep.32143] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 08/13/2021] [Indexed: 12/12/2022]
Abstract
Alcohol-associated liver disease (ALD) is emerging worldwide as the leading cause of liver-related morbidity, mortality, and indication for liver transplantation. The ALD Special Interest Group and the Clinical Research Committee at the digital American Association for the Study of Liver Diseases meeting in November 2020 held the scientific sessions to identify clinical unmet needs in ALD, and addressing these needs using clinical research methodologies. Of several research methodologies, the sessions were focused on (a) studying disease burden of ALD using large administrative databases, (b) developing biomarkers for noninvasive diagnosis of alcohol-associated hepatitis (AH) and estimation of disease prognosis, (c) identifying therapeutic targets for ALD and AH, (d) deriving accurate models to predict prognosis or posttransplant alcohol relapse as a basis for developing treatment algorithm and a uniform protocol on patient-selection criteria for liver transplantation, and (e) examining qualitative research methodologies in studying the barriers to implementation of multidisciplinary integrated care model by hepatology and addiction teams for the management of dual pathology of liver disease and of alcohol use disorder. Prospective multicenter studies are required to address many of these clinical unmet needs. Further, multidisciplinary care models are needed to improve long-term outcomes in patients with ALD.
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Affiliation(s)
- Ashwani K Singal
- Department of Internal MedicineUniversity of South Dakota Sanford School of MedicineSioux FallsSouth DakotaUSA.,Division of Gastroenterology and HepatologyAvera Transplant InstituteSioux FallsSouth DakotaUSA
| | - Paul Kwo
- Division of Gastroenterology and HepatologyStanford University Medical CenterStanfordCaliforniaUSA
| | - Allison Kwong
- Division of Gastroenterology and HepatologyStanford University Medical CenterStanfordCaliforniaUSA
| | - Suthat Liangpunsakul
- Division of Gastroenterology and HepatologyIndiana UniversityIndianapolisIndianaUSA
| | | | - Pranoti Mandrekar
- Graduate School of Biomedical SciencesUMass Medical SchoolWorcesterMassachusettsUSA
| | - Craig McClain
- Division of Gastroenterology, Hepatology, and NutritionDepartment of MedicineUniversity of LouisvilleLouisvilleKentuckyUSA.,Department of Pharmacology and ToxicologyUniversity of Louisville School of MedicineLouisvilleKentuckyUSA.,Alcohol Research CenterUniversity of Louisville School of MedicineLouisvilleKentuckyUSA.,Robley Rex Veterans Affairs Medical CenterLouisvilleKentuckyUSA
| | - Jessica Mellinger
- Division of Gastroenterology and HepatologyUniversity of MichiganAnn ArborMichiganUSA
| | - Gyongyi Szabo
- Division of Gastroenterology and HepatologyBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMassachusettsUSA
| | - Norah Terrault
- Division of Gastroenterology and HepatologyUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Mark Thursz
- Division of Digestive DiseasesImperial College LondonLondonUK
| | - Gerald S Winder
- Department of PsychiatryUniversity of MichiganAnn ArborMichiganUSA
| | - W Ray Kim
- Division of Gastroenterology and HepatologyStanford University Medical CenterStanfordCaliforniaUSA
| | - Vijay H Shah
- Division of Gastroenterology and HepatologyMayo ClinicRochesterMinnesotaUSA
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11
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Zhang Z, Ma L, Geng H, Bian Y. Effects of Smoking, and Drinking on Serum Gamma-Glutamyl Transferase Levels Using Physical Examination Data: A Cross-Sectional Study in Northwest China. Int J Gen Med 2021; 14:1301-1309. [PMID: 33883928 PMCID: PMC8055286 DOI: 10.2147/ijgm.s301900] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 03/31/2021] [Indexed: 11/24/2022] Open
Abstract
Purpose Although drinking and smoking have been associated with gamma-glutamyl transferase (GGT) levels, studies on the effects of smoking and drinking on GGT levels are scarce. The objective of this study was to assess the individual and combined effects of smoking, drinking on GGT levels in the Shaanxi province of Northwest China. Participants and Methods A questionnaire survey was conducted in a population that underwent health examination at the First Affiliated Hospital of Xi’an Jiaotong University and included employees of enterprises or public institutions. The survey was used to collect the baseline characteristics, smoking status, and drinking status of the participants. This information was collected from January 2019 to December 2019. Data related to the physical examinations were exported using the hospital information system (HIS). A linear regression model was employed to explore the effects of smoking and drinking on GGT levels. The restricted cubic spline model was applied to assess the dose–response relationship between amount of smoking, alcohol consumption and GGT levels. Results A total of 10,177 participants were included in the study. Linear regression indicated that smoking (β=3.37, 95% CI: 2.57–4.17) and drinking (β=5.55 L, 95% CI: 4.40–6.71) individually, and collectively (β=9.30, 95% CI: 7.83–10.76) had a positive effect on GGT levels. The restricted cubic spline presented a linear dose–response relationship between the amount of daily smoking and GGT levels (P for non-linearity=0.148, P for overall association <0.001, OR=2.49, 95% CI: 1.27–4.90), and that between weekly alcohol consumption and GGT levels (P for non-linearity=0.231, P for overall association <0.001, OR=4.79, 95% CI: 1.72–13.32). In case of females, stratified analysis showed that in comparison to the reference group, only current drinkers had a significant effect on GGT levels (OR=3.37, 95% CI: 0.19–6.55). Conclusion Smoking and drinking have a dose-dependent and a synergistic effect on GGT levels. They should be controlled concurrently, especially among males.
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Affiliation(s)
- Zhuo Zhang
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macau, People's Republic of China
| | - Lu Ma
- Xi'an Shiyou University, Xi'an, Shaanxi, People's Republic of China
| | - Hui Geng
- Physical Examination Center, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, People's Republic of China
| | - Ying Bian
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Taipa, Macau, People's Republic of China
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12
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Overexpression of ring finger protein 20 inhibits the progression of liver fibrosis via mediation of histone H2B lysine 120 ubiquitination. Hum Cell 2021; 34:759-770. [PMID: 33575967 DOI: 10.1007/s13577-021-00498-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 01/25/2021] [Indexed: 12/16/2022]
Abstract
Liver fibrosis is a chronic liver injury that leads to liver cirrhosis and liver cancer. Ring finger protein 20 (RNF20), also named as E3 ubiquitin-protein ligase BRE1A, has been reported to be involved in chronic liver diseases. However, the role of RNF20 in liver fibrosis remains unclear. To mimic liver fibrosis in vitro, LX-2 cells were treated with TGF-β. Gene and protein expressions were detected by RT-qPCR and western blot, respectively. The mechanism by which RNF20 mediated the progression of liver fibrosis was explored by bioinformatics analysis. Finally, in vivo mouse model of liver fibrosis was established to detect the function of RNF20. The results indicated that TGF-β-induced increase of cell viability and migration was significantly reversed by RNF20 overexpression. Consistently, overexpression of RNF20 significantly reversed TGF-β-induced activation of fibrotic proteins in LX-2 cells. Meanwhile, VEGFA, TNF-α and IL-6 were found to be the downstream targets of RNF20 in LX-2 cells. Moreover, RNF20 overexpression notably inhibited the progression of liver fibrosis via ubiquitination of H2B. Finally, RNF20 upregulation significantly attenuated the symptom of liver fibrosis in vivo. In summary, overexpression of RNF20 significantly inhibited the progression of liver fibrosis in vitro and in vivo. Therefore, RNF20 might serve as a new target for the treatment of liver fibrosis.
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