Controversies in Alcohol-Associated Liver Disease

Overview

This lecture by Prof. Gene Im addresses key controversies in alcohol-associated liver disease (ALD), covering the spectrum from alcohol use disorder (AUD) epidemiology and diagnosis through treatment strategies and liver transplantation, with a U.S.-centered perspective.

Key Clinical Topics

• Language and stigma reform in ALD and AUD
• Epidemiology and changing demographics of AUD
• Screening tools for AUD
• Biomarker testing for alcohol use, including phosphatidylethanol (PEth)
• Pharmacotherapy and behavioral treatment for AUD
• Liver transplantation in alcohol-associated liver disease

Key Learning Points

• Destigmatizing language: Terms such as "alcoholic" and "recidivism" should be replaced with "alcohol-associated liver disease" and "relapse," reflecting AUD as a medical disease, not a behavioral choice
• DSM-5 AUD criteria: Classifies AUD as mild (2–3 criteria), moderate (4–5 criteria), or severe (6+ criteria); most patients with ALD meet at least mild AUD criteria
• AUDIT-C: Most validated screening tool; threshold scores of 3 (women) and 4 (men) indicate risk for AUD; single alcohol screening question is an alternative for time-limited settings
• Phosphatidylethanol (PEth): A metabolite of phosphatidylcholine and ethanol formed via phospholipase D on red blood cell membranes; detects alcohol use for up to 2–4 weeks, outperforming serum ethanol and urine ethylglucuronide; described as the "HbA1c of alcohol disease"
• PEth utility in steatotic liver disease: Recommended as a standard biomarker in patients with suspected steatotic liver disease, including MASLD, to avoid diagnostic miscategorization
• FDA-approved medications for AUD (MAUD): Three agents approved in the U.S. — disulfiram, naltrexone, and acamprosate; best used as adjuncts to behavioral therapy, not as standalone treatment
• Spontaneous AUD remission: Approximately 10–20% of patients achieve remission without formal treatment

Clinical Data & Study Results

• AUD prevalence trends (2002–2013): Nearly 50% rise in AUD prevalence in the U.S.; approximately one-third of U.S. adults have met AUD criteria in their lifetime; 14% met criteria within the past year
• NESARC survey: Fewer than 10% of newly diagnosed AUD patients reported receiving treatment in the past year
• 12-step and outpatient programs: Associated with 50–60% remission rate at one year
• Brief physician intervention: Reduces heavy drinking by approximately 30–40%
• One-on-one psychotherapy: Approximately 50% remission rate at one year
• MAUD added to behavioral therapy: Increases remission rate by an additional 10–20%
• Alcohol biomarker study in steatotic liver disease: Using urine and hair ethylglucuronide, 30% of patients presumed to have MASLD based on history were found to have elevated alcohol consumption; 10% were drinking heavily despite denial; history-based assessment underestimated alcohol use by 70% compared to AUDIT-C

Practical Takeaways

• Adopt non-stigmatizing language in all clinical encounters; use "relapse" rather than "recidivism" and "AUD" rather than "alcoholism"
• Screen all at-risk patients using AUDIT-C or the single alcohol screening question at every clinical encounter
• Incorporate PEth testing routinely in patients with suspected steatotic liver disease, including those labeled as MASLD, to verify self-reported alcohol history
• Prescribe FDA-approved MAUD (e.g., naltrexone, acamprosate, disulfiram) as adjuncts to formal behavioral programs, not as monotherapy
• Counsel patients that spontaneous remission occurs in only ~10% of cases to motivate engagement with formal treatment programs