Redefining Successful Treatment of Severe Alcoholic Hepatitis
Authors: Michael Ronan Lucey
Journal: Hepatology (2017)

Potential conflict of interest: Dr. Lucey received grants from AbbVie and Gilead. See Article On Page 1842 Alcoholic hepatitis (AH) occurs as a critical event in the life of a drinking patient, requiring admission to hospital. For medical caregivers, the events that follow the discharge of those patients who survive are often obscure and given little attention until the next admission. In this issue of hepatology, Altamirano and colleagues provide a fascinating account of the sequel to an admission in 162 patients with well‐characterized AH, 142 of whom survived to be discharged.1 Their study is retrospective, but the process of data collection and focus on drinking history mean that it yields several valuable insights. They selected a severely ill cohort, almost half of whom died in the study period; 20 subjects (12.3%) died during the initial admission, and another 54 (33.3%) died in the follow‐up, which lasted a median of 55 months. Return to alcohol use was simply defined as consumption of an alcoholic drink at least once a week during the follow‐up period. Among the subjects who survived the index admission and were discharged, 86 (60%) returned to alcohol use later on. The authors found that maintenance of complete abstinence after surviving a bout of severe AH was associated with better long‐term survival. Subject age less than 48 years and an absence of prior treatments for alcohol use disorder (AUD) were predictive of establishing abstinence after discharge from hospital. On the one hand, the conclusions of this study, and a similar recent prospective account of survivors of severe AH by Louvet et al. might, appear prosaic.1 It is standard practice to urge patients who survive an episode of severe AH to abstain from alcohol. Whereas previously this advice might have been justified on the basis of common sense, Both studies provide data to support the observation that continued imbibition puts the patient at risk of premature death. Perhaps the most important conclusion of Altamirano et al.'s study is that no treatment of AH is likely to have a substantial impact on patient survival unless it is linked to an effective means to help those patients who survive a bout of AH recover from AUD. Another important contribution of the Altamirano and Louvet studies is to provide the opportunity to reconsider what we mean by successful therapy of AH. Some might see this as a dialogue that can be conducted exclusively in the world of internal medicine and hepatology. On the contrary, I would suggest that to be productive we need to cast a wider net and seek the views of psychiatrists, addiction specialists, social psychologists, and patients with AUD. At its core is the following question: why does someone return to drinking after nearly dying due to alcohol? The answer lies at the nexus of genetic traits, learned behaviors, environmental risks which might be termed "temptations," and volition. Although discussing the genetic foundation for AUD and for alcohol‐related liver disease and the impact of social interventions such as a minimum pricing structure for alcohol on patterns of consumption is beyond this brief review, I would like to discuss three points that relate to the present study. First, I think we need to clarify the nomenclature surrounding drinking. In 1997, Richard Fuller of the National Institute on Alcohol Abuse and Alcoholism suggested that we eschew the term "recidivism" and replace it with "relapse."3 The former term, linked to criminal behavior, is pejorative and adds to the stigma of AUD, which is one of the barriers that works against reaching sobriety. Future studies ought to define drinking behaviors in nonjudgmental terms. The present study was not designed to determine complex patterns of use, as has been achieved by DiMartini et al.'s prospective observation of a cohort of alcohol‐addicted survivors of liver transplantation.4 Future prospective studies should adopt a lexicon of sufficient subtlety to capture the variations of drinking patterns. We should also determine whether to use biomarkers of alcohol use which may yield data on clandestine drinking, and we would need a vocabulary to express these data also.5 Second, it would be wise to address the risks from the patient's perspective of candor about drinking.6 As shown in Altamirano et al.'s cohort, >80% of patients had cirrhosis at the time of presentation. These patients may need to be considered for liver transplantation at some time. Furthermore, 36% of patients with reported complete abstinence experienced at least one decompensation requiring admission during follow‐up. One has to question whether some of these patients had decompensated on account of secretive drinking but had chosen to withhold their history of relapse for fear of reprisal, such as jeopardizing access to transplantation. In a prospective study, I would advise constructing a mechanism to protect patient confidences regarding drinking, just as Weinrieb et al. did in their study of motivational enhancement therapy in patients with AUD who were awaiting liver transplantation.7 Finally, I suggest that we need to recognize that AUD is more than a problem of drinking too much, too often. Its seat is deeper, and its solution will be deeper also. We can learn from the experiences of patients with AUD and from the people who have helped them toward recovery. Here are two observations that illustrate this point. The late film critic and writer Roger Ebert wrote a personal account of overcoming AUD with the assistance of Alcoholics Anonymous.8 In it he noted that "A.A. believes there is an enormous difference between bring dry and being sober. It is not enough to simply abstain. You need to heal and repair the damage to yourself and others." My final observation comes courtesy of George Vaillant, quoting Gerard and Saenger, who wrote concerning their long‐term studies of abstinent AUD patients that "what seemed to have made a difference was a change in the alcoholic's attitude toward the use of alcohol, based on the person's own experiences, which in the vast majority of cases took place outside any clinical interactions."9 It is a paradox that the change in attitude referred to by Gerrard and Singer is most likely to occur outside traditional treatment settings, yet is fundamental to the discovery of therapies for AH that have a more lasting effect beyond short‐term survival. Our challenge in relation to AH is to find a process to study this broader concept of treatment in a manner that yields informative data. My hope is that the National Institute on Alcohol Abuse and Alcoholism would act as the agent of change bringing together the parties who are crucial to developing the innovative treatment studies that address both short‐term care of AH and long‐term recovery from AUD. The studies of Altamirano and Louvet provide a valuable starting point for these discussions.