10/1/2015
Blame it on the Alcohol: Management of Acute Alcoholic Hepatitis
Disclosure Statement
I have nothing to disclose related to the contents of this presentation
Denise Kelley, PharmD, BCPS October 2015
Objectives
Alcoholic Liver Disease
Pharmacist Objectives: • Identify acute alcoholic hepatitis (AH) using various scoring stratification schemes • Compare and contrast literature surrounding treatment strategies of AH • Formulate an evidence based treatment regimen for a patient with AH
Technician Objectives:
Top 10 leading cause of death Major risk factor for liver disease Excessive alcoholism increasingly common
• Define acute alcoholic hepatitis (AH) • Provide examples of treatment strategies for AH • Generalize differences between treatment regimens for AH
Increasing hospitalizations Dugum M, et al. Cleve Clin J Med 2015;82(4):226-36
Acute Alcoholic Hepatitis (AH) Acute hepatic decompensation after longstanding alcohol abuse Steatosis
Liver failure
Fibrosis
Hepatitis
Cirrhosis
Vuittonet CL, et al. Am J Health-Syst Pharm 2014;71:1265-76
Who is at risk?
Women are more likely to develop AH
Most AH-related hospitalizations are men
Can occur even if alcohol consumption significantly reduced or stopped in last few weeks Dugum M, et al. Cleve Clin J Med 2015;82(4):226-36
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Diagnosis of AH
AH Physiology CYP2E1, ADH
Alcohol
Oxidative degradation
Reactive O2 species, Acetaldehyde
LPS from intestines
Kupffer cells activated
Liver injury
Cytokines, TNF, Interleukin
• Mainly clinical diagnosis, no specific lab marker Aspartate aminotransferase (AST) Alanine aminotransferase (ALT) Gamma-glutamyl transpeptidase (GGT) Bilirubin Coagulopathy Hepatic encephalopathy, ascites • Role of liver biopsy
Dugum M, et al. Cleve Clin J Med 2015;82(4):226-36
Scoring Assessment Tools
Gold standard, controversial Dugum M, et al. Cleve Clin J Med 2015;82(4):226-36
Maddrey’s Discriminant Factor (DF) • Validated in 1978
• • • •
Maddrey MELD Glasgow Lille
Maddrey
MELD
• Retrospective review of biopsy proven AH
4.6 x (PT-control PT) + bilirubin
• Identified patients with 50% risk of mortality
Glasgow
Lille
• DF ≥ 32 merits drug therapy
Dugum M, et al. Cleve Clin J Med 2015;82(4):226-36
Maddrey’s Discriminant Factor
Maddrey WC, et al. Gastroenterology 1978;75:193-99
MELD Mayo 9.57 End-Stage Liver Disease (MELD) x loge(SCr) + 3.78 x loge(bili) Predictor of chronic disease +11.20 x logliver + 6.43 mortality e(INR)
Maddrey WC, et al. Gastroenterology 1978;75:193-99
Retrospective Analysis
Pts (n)
Comparison Assessment Tool
Outcome
Sheth, et al
34
Maddrey’s DF
Accurate predictor of 30-day mortality; MELD >11
Dunn, et al
73
Maddrey’s DF
Accurate predictor of 30-day and 90-day mortality
Srikureja, et al
202
Maddrey’s DF, Child Pugh
Better predictor of 30-day and 90- day mortality; MELD >18 Sheth M, et al. BMC Gastroenterol 2002;2:2 Dunn W, et al. Hepatology 2005;41:353-8 Srikureja W, et al. J Hepatol 2005;42:700-6
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Glasgow (GAHS)
Lille
• Derived from 241 patients from Glasgow • 144 patients with Maddrey’s DF ≥ 32 assessed ▫ 64% found to have GAHS ≥ 9
Score
1
2
3
Age
