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Treatment of alcoholic liver disease

INTRODUCTION — There are at present few specific therapies available for patients with alcoholic liver disease. There is, however, one extremely important intervention — abstinence — since continued alcohol ingestion is the single most important risk factor for progression in patients with alcoholic liver disease. Abstinence is also critical for those patients with advanced disease who may eventually require liver transplantation; in this setting, continued drinking will remove the patient from consideration. Referral to a rehabilitation program is usually necessary in combination with family support and counseling.

PREVENTION — Abstinence is the most effective means to prevent alcohol-related liver injury. In addition, several drugs have been studied to improve rates of abstinence but none is used routinely.

Abstinence — Abstinence can be beneficial even in patients with advanced histologic and clinical features. Improvement in fibrosis, a reduction in or even normalization of the portal pressure , and resolution (or easier treatment) of ascites have accompanied alcohol abstinence in some patients.

Disulfuram — Disulfuram, approved by the FDA in 1983, inhibits the activity of ALDH and, after alcohol ingestion, results in plasma acetaldehyde levels 5 to 10 times that seen in the absence of disulfuram. The accumulation of acetaldehyde leads to facial flushing, tachycardia, hypotension, dyspnea, nausea, vomiting, headache, blurred vision, vertigo, and anxiety within 15 to 30 minutes of alcohol ingestion. The syndrome lasts for several hours and the inhibitory activity lasts for several days. Due to its poor tolerability and "black box" warning regarding use in patients who are actively drinking, there is little evidence showing that disulfuram encourages abstinence.

Naltrexone — Naltrexone, a pure opioid antagonist, approved in 1995 for the treatment of alcoholism, controls the craving for alcohol. However, it also has a black box warning related to its potential for hepatocellular injury. In a review of 29 randomized controlled trials of naltrexone and nalmefene (another opioid antagonist), short-term treatment with naltrexone lowered the risk of relapse of alcohol abuse.