Diagnosis and Treatment of Alcohol‐Associated Liver Diseases: 2019 Practice Guidance From the American Association for the Study of Liver Diseases

Supported by the American Association for the Study of Liver Diseases. Potential conflict of interest: Dr. Lucey received grants from Gilead, AbbVie and Pharmasolutions. Dr. Szabo consults and received grants from Allergan. She consults for Terra Firma, Glympse, Quest, Arrow, GLG, Salix and Tobira. She received grants from Gilead, Genfit, Intercept, Verlyx, Novartis, SignaBlok and Shire. She holds intellectual property rights with Up to Date. Purpose and Scope of the Guidance Alcohol‐associated liver disease (ALD) represents a spectrum of liver injury resulting from alcohol use, ranging from hepatic steatosis to more advanced forms including alcoholic hepatitis (AH), alcohol‐associated cirrhosis (AC), and acute AH presenting as acute‐on‐chronic liver failure. ALD is a major cause of liver disease worldwide, both on its own and as a co‐factor in the progression of chronic viral hepatitis, nonalcoholic fatty liver disease (NAFLD), iron overload, and other liver diseases. ALD develops through several stages, beginning with hepatic steatosis, and, in some individuals, gradually progressing through AH (the histological correlate of which is alcoholic steatohepatitis), culminating in cirrhosis (Fig. 1).1 Progression through these various stages is dependent on continued heavy alcohol use and other risk factors, including female sex, genetic susceptibility, diet, and comorbid liver disease. ALD carries a significant stigma in society. It is increasingly recognized by providers that patients and their families seek to reduce the stigma of ALD, and a change from the term “alcoholic” to “alcohol‐associated” will help; thus, alcohol‐associated liver disease, alcohol‐associated steatohepatitis, and alcohol‐associated cirrhosis are suggested, retaining the familiar abbreviations (ALD, ASH, and AC, respectively). Due to longstanding usage, the term “alcoholic hepatitis” will likely persist.Figure 1: Natural history of alcohol‐associated liver disease. Images courtesy of Dr. M. Isabel Fiel.This 2019 ALD Guidance provides a data‐supported approach to the prevalence, clinical spectrum, diagnosis, and clinical management of ALD and alcohol use disorders (AUDs). The Guidance was developed by consensus of an expert panel and provides guidance statements based on formal review and analysis of published literature on the topics. The quality (level) of the evidence and the strength of each guidance statement are not formally rated. Updates to the 2010 Guideline include an emphasis on AUD definition, screening, and treatment; new alcohol biomarkers; additional genetic and environmental susceptibility factors; a consensus definition of AH, and review of recent studies of corticosteroids and guidance on the role of transplantation in the management of AH. Prevalence and Burden of Alcohol‐Associated Liver Disease Alcohol‐associated liver disease includes a variety of clinical disorders: steatosis, ASH, AH of varying degrees of severity, AC, and AC complicated by hepatocellular carcinoma (HCC). ALD comprises a substantial portion of the overall cirrhosis burden, both in the United States and worldwide, and is responsible for rising rates of liver‐related mortality in the United States, especially among younger patients.3 In the United States, mortality due to all ALD was estimated at 5.5 per 100,000 in 2012; the relative contribution of ALD to all cirrhosis mortality is predicted to increase as the proportion of deaths due to hepatitis C virus (HCV) cirrhosis declines.3 More recently, AC mortality was shown to have increased from 2008 to 2016, particularly among patients ages 25‐34 years old.4 Cirrhotic and noncirrhotic ALD prevalence has estimated at in the AC in the was estimated at per 100,000 In AC has estimated at per 100,000 and, rates are to AC deaths for of all and of deaths are due to liver disease, resulting in the of years In the United States, ALD with chronic as the for liver transplantation are for AC, in by the of for these In deaths to alcohol use are due to the stigma of alcohol use and of in In AC prevalence at a in the in alcohol use in in the United The of AH has to as of is for The of AH In the United States, for AH to have increased to of all for In the of AH for the from to per per in and to per per for in increased rates for AH from to per per for and from to per per for In both of these based on which and the in the of AH. of the spectrum of ALD prevalence is particularly the with stages of ALD, as AH, that with use of steatosis and and increased for the to disease. studies the prevalence and by as ALD patients additional liver as in of the that ALD rates are as as in some patients with other liver in nonalcoholic and in as as a for of of the and the of alcohol and have by the term use as based on the of and use is in the United States, with significant more forms of by alcohol to and the of alcohol are on the of AUD and have with the prevalence of AUD in of by and with among and of The of alcohol and the prevalence of more more 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