Sunday, April 29, 2018

New alcoholic liver disease guidelines from the American College of Gastroenterology

The document is worth reading in its entirety, but there were a few points I found particularly noteworthy:

Patients who are obese should not consume any ethanol at all!

Definitions, from the paper:

Alcoholic fatty liver disease is diagnosed in a patient with AUD with hepatic steatosis on ultrasound and/or elevation in liver enzymes (aspartate aminotransferase (AST) greater than alanine aminotransferase (ALT)), serum bilirubin less than 3 mg/dL, and the absence of other causes of liver disease.

Clinical diagnosis of AH is determined in a patient with rapid development or worsening of jaundice and liver-related complications, with serum total bilirubin greater than 3 mg/dL; ALT and AST elevated greater than 1.5 times the upper limit of normal but less than 400 U/L with the AST/ALT ratio greater than 1.5; documentation of persistent heavy alcohol use until 8 weeks before onset of symptoms; and exclusion of other liver diseases

Baclofen to help patients stop drinking has a conditional recommendation:

In patients with ALD, baclofen is effective in preventing alcohol relapse (Conditional recommendation, low level of evidence).

Pentoxifylline is no longer recommended for severe alcoholic hepatitis. Steroids still are.

At 7 days into steroid therapy the Lille score should be used to determine if the steroids should be continued:

Response to treatment with corticosteroids should be determined at 7 days using the Lille score. Treatment should be discontinued among non-responders to therapy, defined as those with a Lille score greater than 0.45.

The guideline authors acknowledge evidence that N-acetylcysteine infusion in combination with steroids may be associated with improved outcomes in AH. However, they do not feel the evidence is sufficiently strong to justify a guideline recommendation.

Antibiotic therapy is still recommended as part of the overall treatment regimen for variceal bleeding:

Management of the acute variceal bleeding episode involves pharmacological therapy with available vasoactive agents (terlipressin or octreotide), antibiotics, and endoscopic therapy. Endoscopy should ideally be carried out at least 30 min after initiation of vasoactive therapy (54).

As for the optimal timing of endoscopy, that last sentence is confusing to me.

Have a low threshold for starting broad spectrum antibiotics in AH patients who become critical.  

Concerning the gram negative component of the regimen, the guideline recommends merropenem or zosyn, acknowledging that the clinician should pay attention to local sensitivity patterns:

The choice of antibiotics depends on prevailing local antimicrobial resistance patterns. Piperacillin-tazobactam is generally the preferred drug used for sepsis, although vancomycin and meropenem may be considered in patients with penicillin hypersensitivity.

There’s much more.

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