alcoholic liver disease

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Alcoholic liver disease:

Alcoholic liver disease Prepared & Presented by Dr. Siva Reddy Challa, M.Pharm,Ph.D Professor & HOD, Dept. of Pharmacology KVSR Siddhartha College of Pharmaceutical Sciences, Siddhartha Nagar, Vijayawada-520010 Andhra Pradesh, INDIA Email: m

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Recommendation: 1. Clinicians should discuss alcohol use with patients, and any suspicion of possible abuse or excess should prompt use of a structured questionnaire and further evaluation. 2. For patients with a history of alcohol abuse or excess and evidence of liver disease, further laboratory tests should be done to exclude other etiologies and to confirm the diagnosis. 3. Patients with ALD and suggestive symptoms should be screened for evidence of other end-organ damage, as appropriate.

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Recommendation: 4. For patients with a clinical diagnosis of severe AH for whom medical treatment is contemplated, or for those in whom reasonable uncertainty exists regarding the underlying diagnosis, a liver biopsy should be considered. This decision will depend on local expertise and ability in performing a liver biopsy in patients with coagulopathy, the patient’s severity of illness, and the type of therapy under consideration. 5. Patients presenting with a high clinical suspicion of alcoholic hepatitis should have their risk for poor outcome stratified using the Maddrey Discriminant Function , as well as other available clinical data. Evaluating a patient’s condition over time with serial calculation of the MELD score is also justified.

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Recommendation: 6. In patients with evidence of alcohol-induced liver disease, strict abstinence must be recommended, because continued alcohol use is associated with disease progression. 7. Naltrexone or acamprosate may be considered in combination with counseling to decrease the likelihood of relapse in patients with alcohol abuse/dependence in those who achieve abstinence. 8. All patients with alcoholic hepatitis should be counseled to completely abstain from alcohol. 9. All patients with alcoholic hepatitis or advanced ALD should be assessed for nutritional deficiencies (protein-calorie malnutrition), as well as vitamin and mineral deficiencies. Those with severe disease should be treated aggressively with enteral nutritional therapy.

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Recommendation: 10. Patients with mild-moderate alcoholic hepatitis— defined as a Maddrey score of <32, without hepatic encephalopathy, and with improvement in serum bilirubin or decline in the MDF during the first week of hospitalization—should be monitored closely, but will likely not require nor benefit from specific medical interventions other than nutritional support and abstinence. 11. Patients with severe disease (MDF score of >32, with or without hepatic encephalopathy) and lacking contraindications to steroid use should be considered for a four week course of prednisolone (40 mg/day for 28 days, typically followed by discontinuation or a 2-week taper).

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Recommendation: 12. Patients with severe disease (i.e., a MDF > 32) could be considered for pentoxifylline therapy (400 mg orally 3 times daily for 4 weeks), especially if there are contraindications to steroid therapy. 13. Patients with alcoholic cirrhosis should receive frequent interval feedings, emphasizing a night time snack and morning feeding, to improve nitrogen balance. 14. PTU and colchicine should not be used in the treatment of patients with ALD; SAMe should be used only in clinical trials. 15. The use of complementary or alternative medicines in the treatment of either acute or chronic alcohol-related liver disease has shown no convincing benefit and should not be used out of the context of clinical trial.

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Appropriate patients with end-stage liver disease secondary to alcoholic cirrhosis should be considered for liver transplantation, just as other patients with decompensated liver disease, after careful evaluation of medical and psychosocial candidacy. In addition, this evaluation should include a formal assessment of the likelihood of long-term abstinence.

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