Top tips:
- Abstinence from alcohol is the best way to improve outcomes in patients with alcohol-related cirrhosis. In alcohol related liver disease, even 1 or 2 drinks per day can increase mortality.
- Some patients won’t be ready or able to quit completely. For those patients who struggle to quit completely, continue to support them with encouragement, motivational interviewing and pharmacotherapy to help them achieve abstinence.
- It is important to screen for concurrent mental health concerns alongside addiction. Patients with these issues require further management.
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General Cirrhosis Admission and Discharge Order Sets
*Add specific panels to general admission orders as appropriate*
For adults with cirrhosis requiring hospital admission
Cirrhosis Adult Admission Orders
For adults with cirrhosis requiring hospital discharge
Cirrhosis Adult Discharge Orders
Check out the bottom of the page for short videos from Dr. Mellinger and Dr. Ghosh!
Diagnosis
AUD-1
| Medication: | Acamprosate |
|---|---|
| Dose: | 666 mg po TID; 333 mg po TID if renal impairment (CrCl 30 to 50 mL/min) or weight <60 kg; Generally abstinence for >3 days before initiation, although studies show reduction in heavy drinking days even when initiated prior to abstinence. |
| Contraindications: | Creatinine clearance <30 ml/min |
| Considerations: | Pregnancy risk category ‘C’; As above, consider in pregnant women if potential benefit outweighs risk; Although TID dosing is cumbersome, it may be useful for patients who cannot take naltrexone due to liver disease or taking opioids or with polypharmacy because no significant interactions with other drugs; Caution if depression or suicidal ideation; |
| Side Effects: | GI upset ; somnolence, rarely suicidality |
| Monitoring: | Initial close weekly follow-up may be helpful; Monitor renal function and adjust dose if CrCl 30-50 ml/min |
| Health Canada for AUD: | Approved |
| Coverage: | Funded via Special Authorization Request Form for Income Support, AISH or AB Adult Health Benefit. View Alberta Blue Cross Drug Special Authorization Request. Limited use benefit under NIHB (abstinent >3 days and enrolled in treatment program where available, prior approval required). |
| Est. cost with no coverage | ~ $200/mo. |
| Medication: | Gabapentin |
|---|---|
| Dose: | With history of Hepatic Encephalopathy: Start low dose – 100 mg po TID and titrate up as tolerated. Without Hepatic encephalopathy: 300 mg po day one, 300 mg po BID day 2 ; 300 mg po TID day 3; increasing by 300 mg po each day up to 600 mg TID on day 6 as tolerated; abstinence at 12 weeks 4.1% placebo group; 11.1% gabapentin 900 mg/day; 17% for 1,800 mg/day. |
| Contraindications: | Decrease dose with renal impairment. Start at lower doses with Hepatic encephalopathy. |
| Considerations: | Risk of dependence in post-marketing database; increased risk of CNS depression esp. with opioids and other CNS depressants; Pregnancy risk category ‘C’; Consider in pregnant women if potential benefit outweighs risk |
| Side Effects: | Somnolence, dizziness, ataxia, fatigue, nystagmus, tremor |
| Monitoring: | Routine monitoring not required; consider if renal impairment |
| Health Canada for AUD: | Not approved |
| Coverage: | Drug benefit under Income Support, AISH, AAHB, NIHB and CFS |
| Est. cost with no coverage | ~$30/mo. partial coverage by many drug plans |
| Clinical pearls: | Gabapentin has some off-label utility in treating mild to moderate alcohol withdrawal which means it can be useful in early sobriety particularly in AUD patients who have comorbid anxiety and/or insomnia alongside their other symptoms. It is also another good medication for patients with comorbid neuropathic pain. Requires attention to kidney function due to renal clearance and could worsen hepatic encephalopathy due to potential sedating effects. |
| Medication: | Baclofen |
|---|---|
| Dose: | Initiated at 5mg TID with increases 3-5 days based on patient tolerance and absence of side effects. The maximum recommended dose for alcohol related liver disease is 15mg TID. Higher doses can be tried but with extreme caution due to limited evidence and increased risk of side effects |
| Contraindications: | Care must be taken in patients with both renal and liver disease. This drug should be avoided in individuals with hepatic encephalopathy. Due to a lack of studies, baclofen should be avoided in pregnant patients. Baclofen toxicity can lead to overdose. Caution must be taken for individuals with severe suicide risk. |
| Considerations: | The maximum recommended dose for alcoholic liver disease is 15mg TID. Care must be taken for patients with renal failure or hepatorenal failure, as baclofen is predominantly excreted renally, and impairments in excretion can lead to delirium, and drug toxicity and doses of 5mg TID max should be prescribed in this setting. Operation of heavy machinery is discouraged when first using the medication until they learn how the sedation affects them or they reach a stable dose. |
| Side Effects: | Severe sedation, dizziness, and/or confusion. Potentially dangerous side effects are seizures, respiratory depression with sleep apnea and potentially coma (in case of intoxication), severe mood disorders (mania or depression, with the risk of suicide), and mental confusion/delirium |
| Monitoring: | No specific monitoring required. |
| Health Canada for AUD: | Not approved |
| Coverage: | Drug benefit under Income Support. Covered by many private drug plans. |
| Est. cost with no coverage | If 80% covered by a private drug plan, cost to patient: $6/month, based on 60 mg daily. Cost to patient if no coverage: $28/month. |
| Medication: | Notes: |
|---|---|
| Naltrexone | In the US, naltrexone is a first-line and FDA-approved medication whose utility in AUD is often in patients trying to gain early sobriety or who commonly relapse due to its ability to reduce heavy drinking and dampen cravings. It has been shown to have a larger effect size than Acamprosate in some studies but its use is limited in liver disease patients due to drug-related LFT elevation and metabolite accumulation in hepatic insufficiency. We are not using naltrexone in patients with disease more severe than Childs Pugh A. It is contraindicated in patients using opioids. |
| Disulfiram | Should not be used in patients with liver disease. |
| Topiramate | Has some off-label utility in promoting AUD sobriety and may be adjunctively useful in patients who have co-occurring weight-related challenges. Requires attention to kidney function due to renal clearance and could worsen hepatic encephalopathy due to potential sedating effects |
| Varenicline | May also have some off-label effect in reducing alcohol craving and consumption alongside its treatment of nicotine dependence. It requires attention to renal function for dosing. |
| Ondansetron | Has been shown to reduce alcohol use as an off-label treatment though we have little experience using it for this purpose. |
Pearls from the UMichigan integrated care team
| Medication: | Notes: |
|---|---|
| Naltrexone | In the US, naltrexone is a first-line and FDA-approved medication whose utility in AUD is often in patients trying to gain early sobriety or who commonly relapse due to its ability to reduce heavy drinking and dampen cravings. It has been shown to have a larger effect size than Acamprosate in some studies but its use is limited in liver disease patients due to drug-related LFT elevation and metabolite accumulation in hepatic insufficiency. We are not using naltrexone in patients with disease more severe than Childs Pugh A. It is contraindicated in patients using opioids. |
| Disulfiram | Should not be used in patients with liver disease. |
| Topiramate | Has some off-label utility in promoting AUD sobriety and may be adjunctively useful in patients who have co-occurring weight-related challenges. Requires attention to kidney function due to renal clearance and could worsen hepatic encephalopathy due to potential sedating effects |
| Varenicline | May also have some off-label effect in reducing alcohol craving and consumption alongside its treatment of nicotine dependence. It requires attention to renal function for dosing. |
| Ondansetron | Has been shown to reduce alcohol use as an off-label treatment though we have little experience using it for this purpose. |
Introducing Dr. Mellinger and Dr. Ghosh
Video 1 – Practical tips on how to decide if a patient with cirrhosis needs alcohol use disorder therapy, if they are ready for it and what agent to choose.
Video 2 – Practical tips to accessing support for alcohol use disorder therapy in Alberta – how to refer your patient for counselling and how to get help with prescribing relapse prevention medications.
Patient materials:
You can direct patients to the following:
Healthy Living-Alcohol
Causes of liver disease – Alcohol
Alberta Health Services Addiction and Mental Health Information Page for Health Professionals
Alberta Addiction Service Providers
Link to the Edmonton Canadian Mental Health Association
Alberta Addiction Treatment Centres
Provincial Detox & Substance Use Treatment Facility Directory
Downloadable content:
You can download these to print or view offline:
AASLD guidance statement 2019
Incorporating Alcohol Pharmacotherpies Into Medical Practice. A Treatment Improvement Protocol
References:
This section was adapted from content using the following evidence based resources in combination with expert consensus. The presented information is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient’s care.
Authors: Dr. Monty Ghosh, Dr. Jessica Mellinger, Dr. Kathryn Dong, Dr. Laura Evans, Dr. Nicholas Mitchell, Dr. Meredith Borman, Dr. Scott G Winder, Emily Johnson, Dr. Puneeta Tandon
References:
- Crabb DW et al. Diagnosis and Treatment of Alcohol-Related Liver Diseases: 2019 Practice Guidance from the American Association for the Study of Liver Diseases. Hepatology 2019 July 17 epub ahead of print, PMID 31314133
Last reviewed November 3, 2022