Focus on alcohol misuse and health consequences

On the second day of the Irish Society of Gastroenterology Summer Meeting delegates gathered to hear a virtual presentation on IL-23 antagonists in IBD by Prof Laurent Peyrin-Biroulet, Consultant Gastroenterologist, Lorraine University, France. He discussed the role of IL-23 antagonists in patient care, presenting data on their effectiveness in treatment. Prof Peyrin-Biroulet then presented research on the use of risankizumab in patients with CD and noted high mucosal healing rates relative to placebo in both bio-naive and bio-failure patients.

Alcohol

Later in the day, there were two sessions on alcohol misuse and health consequences. Dr Audrey Dillon, Consultant Hepatologist, SVUH, Dublin, opened the first session with a presentation on ‘Liver transplant for alcohol-related liver disease (ARLD) in Ireland: What’s new in 2024’.

The former Medical Council Vice-President began by outlining current practices at SVUH, including the “six-month rule” on alcohol abstinence for liver transplant candidates. She noted, however, that evidence to support the rule, which is validated with a negative Peth test, is poor. In reality, she said, longer abstinence periods occur as referrals are often only received after six months. Research presented on the rule highlighted that it is “questionable and not evidence-based” and illustrates that liver transplant candidates should not be selected solely on a fixed abstinence interval.

Dr Dillon then presented data showing self-reported alcohol relapse rates of between 30 and 40 per cent at five years post-transplant for patients in this category. She explained that the risk of “severe relapse” is higher among younger people and those with shorter abstinence periods. In order to prevent relapses post-transplant, she said that greater social supports, an acknowledgement of addiction, and awareness of the negative consequences of relapse are important considerations.

Dr Dillon noted the use of psychosocial assessments for candidates and how efforts are underway at SVUH to perform such assessments more frequently. Early referral to a dietician is significant, along with the use of risk scores for relapse. It is helpful, she advised, to refer patients to some form of alcohol service for relapse prevention. Furthermore, she added, it is important to request as much information as possible on a patient’s history from their GP during the assessment process for transplant.

Dr Dillon noted that alcohol support services and resources are available in Ireland – but could be much better. Nevertheless, doctors should always encourage patients to seek counselling, she said.

Dr Dillon paid particular attention to the fact that smoking is an important and often unacknowledged factor in liver disease. Smokers, she said, have poorer survival rates post-transplant than non-smokers, which is why more emphasis should be placed on cessation.

She presented data showing the peak year for orthotopic liver transplantation in Ireland was in 2019, with 66 procedures occurring. Ireland continues to lag well behind other European countries in terms of liver transplants undertaken per million population and improved structures are needed in order to increase numbers.

At SVUH, more resources for a holistic psychosocial assessment are required. More ICU beds and more donor livers are also needed, Dr Dillon said. She concluded by saying that the period of alcohol abstinence is a starting point for assessment but should not be the final point. Hopefully, she said, more transplant opportunities for sicker patients with ARLD can be offered before they become too sick for transplant. “Change is needed throughout the patient journey,” she said.

The second session on alcohol began with a presentation by Prof Alastair MacGilchrist, Chair, Scottish Health Action on Alcohol Problems, Royal College of Physicians of Edinburgh, Scotland, titled: ‘Why alcohol public health policy matters to gastroenterologists.’

Prof MacGilchrist, who has spent much of his life working as a liver transplant physician, told delegates how population measures to reduce alcohol consumption can have a huge impact on society. Clinicians, he argued, are currently “mopping the floor” with regard to alcohol use. He argued that there was the need to “turn off the tap”. He said that in Ireland and Scotland, alcohol-specific deaths are mostly due to liver disease, are twice as common in men as in women, occur mostly in middle age, and are commonest in areas of greatest deprivation.

Alcohol, he argued, is cheaper than it used to be and there is a close relationship between alcohol costs and consumption.

Measures to reduce harm include regulating alcohol distribution, restricting or banning alcohol advertising, and increasing prices. Greater education in schools and voluntary regulation by the alcohol industry are ineffective strategies in reducing harm, he said.

Prof MacGilchrist spoke about the introduction of minimum unit pricing in Scotland and its positive impact in reducing alcohol consumption and alcohol-specific deaths, particularly among deprived populations. But unfortunately, Covid-19 has been “very bad for alcohol deaths and harm” in the UK, data presented by Prof MacGilchrist showed, and has made the “problem worse”.

He underscored the importance of clinicians in helping to reduce alcohol harms. This is because clinicians, he argued, are trusted by politicians and the media as alcohol policy advocates. “Alcohol harm affects all areas of medicine, and all clinicians can help fight stigma and facilitate treatment,” he said. “Despite the power and influence of the alcohol industry trusted clinicians can advocate successfully for effective alcohol policies.”

The final speaker at the meeting ahead of the panel discussion on alcohol misuse and health consequences was Prof Michael Curry, Director of Hepatology, Beth Israel Deaconess Medical Centre, Boston, US.

His presentation, titled: ‘Dismantling the barriers to early transplantation for ARLD’ focused on the need to consider early liver transplantation (eLT) for patients with alcohol-associated liver disease. He described the “six-month rule”, outlined above, as a punitive measure designed to limit access to transplantation. The rule is not adhered to at his centre, he said, and no specific or defined period of sobriety is considered when selecting eLT candidates.

Relapse, contended Prof Curry, should not be classified as a failure and should be expected. Harm reduction and not abstinence should be the focus, he added. “The enemy of good should not be perfect.” The need for eLT among this cohort of patients has increased, as younger people are dying from ARLD and hospital admissions for alcohol-related hepatitis are increasing, he said.

Modelling scores can be utilised to identify the severity of alcohol-associated hepatitis among patients and identify suitable patients for eLT. Written protocols, defined goals, and institutional support and backing are among the requirements for successful eLT, he said.

Adequate resources and staffing for pre- and post-transplant behavioural health teams are needed along with appropriate referrals and regional agreements with other transplant centres.

During the panel discussion, some doctors questioned how the problematic culture around alcohol in Ireland could be changed. Prof MacGilchrist advised that it is a mistake to think there is “an inevitability around this”. He argued that effective advertising and marketing techniques reinforce the “normality” around having alcohol linked to social occasions, for example. “It’s seen as abnormal if we don’t do it. We need to reduce the expectation that this is normal,” he said.